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'General Quarters' 
Page 13 


- Winter Clinical Conference 
January 27-23 

Volume 79 Number 1 
January 1983 






TRY AIR FORCE 


*A 


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like your medical practice to be. More time to practice medi- 
cine. More time with your family. Even more time for your 
hobbies. It’s all part of Air Force EXPERIENCE. Talk to a 
member of our medical placement team today. Find out how 
you can experience the perfect medical practice as an AIR 
FORCE PHYSICIAN. 


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For further information call collect: 

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Norfolk (804) 441-6412 



The West Virginia Tledical Journal 

Official Publication of the West Virginia State Medical Association 

POST OFFICE BOX 1031 . CHARLESTON, W. VA. 25324 

Telephone (304) 346-0551 

© 1983, West Virginia State Medical Association 


EDITOR 

Stephen D. Ward, M. D. (1984) 
Wheeling 

MANAGING EDITOR AND 
BUSINESS MANAGER 
Mr. Charles R. Lewis 
Charleston 

EXECUTIVE ASSISTANT 
Mr. Custer B. Holliday 
Charleston 

ASSOCIATE EDITORS 
David Z. Morgan, M. D. (1983) 
Morgantown 

John M. Hartman, M. D. (1985) 
Charleston 

Vernon E. Duckwall, M. D. (1986) 
Elkins 

Thomas J. Holbrook, M. D. (1987) 
Huntington 

L. Walter Fix, M. D. (1988) 
Martinsburg 

Joe N. Jarrett, M. D. (1989) 

Oak Hill 


Published monthly by the West 
Virginia State Medical Association 
under the direction of the Publica- 
tion Committee. Original articles are 
accepted on condition that they are 
contributed solely to The Journal. 

Postmaster send form 3579 to 
The West Virginia Medical Journal, 
P. O. Box 1031, Charleston, WV 
25324. 

Entered as second-class matter 
January 1, 1926, at the post office 
at Charleston, West Virginia, under 
the act of March 3, 1879. 

Subscription Rates: $10 a year in 
the U.S.A.; $15 in foreign countries; 
$2 per single copy. Advertising rates 
furnished on request. Address all 
communications to Business Manager, 
The West Virginia Medical Journal, 
Box 1031, Charleston, West Virginia 
25324. Phone 346-0551. 

Microfilm editions beginning with 
the 1972 volume are available from 
University Microfilms, Inc., 300 N. 
Zeeb Road, Ann Arbor, Michigan 
48106. 

MEMBER, WEST VIRGINIA 
PRESS ASSOCIATION, 1983 

USPS 676 740 
ISSN 0043 - 3284 


CONTENTS 


Scientific Articles 

Metastatic Cancer of Unknown Origin: Ohio Valley 
Medical Center Experience — Gurijala N. Reddy, 

M. D. 23 

Epikeratophakia: A New Treatment For Corneal 
Irregularity and Keratoconus — Theodore P. 
Werblin, M. D„ Ph.D. 26 

Tension Pneumothorax During Anesthesia — Stephen 
T. Pyles, M. D.; David A. Haught, M. D.; Elmer T. 
Vega, M. D.; and Eduardo A. Rivas, M. D. 29 

Scientific Department 

Medical Grand Rounds From the West Virginia Uni- 
versity Medical Center (Relapsing Polychon- 
dritis)— Edited by Irma H. Ullrich, M. D. 32 

The President’s Page 

Our Legislative Program — Harry Shannon, M. D.: 
President, W. Va. State Medical Association 40 

Editorials 

Priority Goof 41 

Clark Kendall Sleeth, 1913-1982 41 

Gold Rush 42 


General News 

Annual Meeting Program Taking Shape 
AMA-FTC Dispute In Congress In Deadlock 
Family Physicians Meet In April 
WVU Hospital Post Filled 
Continuing Education Activities 
New WVU Dean Said 'Outstanding’ 


Special Departments 

WVU Medical Center News x 

Third-Party News, Views, Program Concerns xii 

Obituaries xiv 

County Societies xviii 

Classified Section xxiii 

Index To Advertisers xxiv 


43 

43 

44 

45 

46 

47 


February, 1983, Vol. 79, No. 2 


iii 


UNIQUE 


nr 

j hat’s what each of 

i | our patient’s needs 

are. And we have 
the medical and professional 
staff to meet these needs. 

In 1980, Saint Albans 
Psychiatric Hospital opened a 
$7.8 million building with 162 
beds and expanded clinical 
facilities. The hospital is fully 
accredited by the Joint Com- 
mission on the Accreditation 
of Hospitals. 

In addition to our general 
psychiatric services, we offer 
specific programs for alcohol- 
ics and substance abusers, 
children/adolescents, and 
older adults. 

Saint Albans, the only 
private, not-for-profit psychia- 
tric hospital in Virginia, has 
served southwestern Virginia 
since 1916. 

When you have a patient 
who needs the specialized ser- 
vices of a psychiatric hospital, 
call Saint Albans. Admission 
can be arranged 24 hours a 
day by calling 703 639-2481. 



ctive Medical Staff: 


Rolfe B. Finn, M.D., Medical Director 
William D. Keck, M.D. 

Morgan E. Scott, M.D. 

Don L. Weston, M.D. 

Davis G. Garrett, M.D. 

D. Wilfred Abse, M.D. 

Hal G. Gillespie, M.D. 

Basil E. Roebuck, M.D. 

O. LeRoyce Royal, M.D. 


A 


Saint Albans 
Rsychratric Hospital 


P. o. Box 3608 
Radford, Virginia 24143 

Saint Albans Psychiatric Hospital is approved for Blue Cross, 
Cham pus, Medicare, and most major insurance companies. 
For a free brochure, write Robert L. Terrell, Jr., administra- 
tor, P. O. Box 3608, Radford, Virginia 24143. 


The West Virginia radical Journal 

Official Publication of the West Virginia State Medical Association 

POST OFFICE BOX 1031 • CHARLESTON, W. VA. 25324 

Telephone (304) 346-0551 

© 1983, West Virginia State Medical Association 


EDITOR 

Stephen D. Ward, M. D. (1984) 
Wheeling 

MANAGING EDITOR AND 

BUSINESS MANAGER 

Mr. Charles R. Lewis 
Charleston 

EXECUTIVE ASSISTANT 

Mr. Custer B. Holliday 
Charleston 

ASSOCIATE EDITORS 

David Z. Morgan, M. D. (1983) 
Morgantown 

John M. Hartman, M. D. (1985) 
Charleston 

Vernon E. Duckwall, M. D. (1986) 
Elkins 

Thomas J. Holbrook, M. D. (1987) 
Huntington 

L. Walter Fix, M. D. (1988) 
Martinsburg 

Joe N. Jarrett, M. D. (1989) 

Oak Hill 


Published monthly by the West 
Virginia State Medical Association 
under the direction of the Publica- 
tion Committee. Original articles are 
accepted on condition that they are 
contributed solely to The Journal. 

Postmaster send form 3579 to 
The West Virginia Medical Journal, 
P. O. Box 1031, Charleston, WV 
25324. 

Entered as second-class matter 
January 1, 1926, at the post office 
at Charleston, West Virginia, under 
the act of March 3, 1879. 

Subscription Rates: $10 a year in 
the U.S.A.; $15 in foreign countries; 
$2 per single copy. Advertising rates 
furnished on request. Address all 
communications to Business Manager, 
The West Virginia Medical Journal, 
Box 1031, Charleston, West Virginia 
25324. Phone 346-0551. 

Microfilm editions beginning with 
the 1972 volume are available from 
University Microfilms, Inc., 300 N. 
Zeeb Road, Ann Arbor, Michigan 
48106. 

MEMBER, WEST VIRGINIA 
PRESS ASSOCIATION, 1983 

USPS 676 740 
ISSN 0043 - 3284 


CONTENTS 


Scientific Articles 

Acquired Factor VIII Inhibitor (A Case Report) — 
Susan Irby, M. D.: John S. Rogers II. M. D.; and 
Douglas C. Wolf, M. D. 49 

Early Attenuation Of Toxic Shock Syndrome With 
Intravenous Nafcillin Sodium — Thomas T. Smir- 
niotopoulos, M. D.; and Vettivelu Maheswaran, M. D. 52 

The President’s Page 

This One’s For You — Harry Shannon, M. D„ President, 


W. Va. Medical Association 56 

Editorials 

Rigorous Standards 57 

Save Now, Pay Later? 57 

On The Artificial Heart 58 

More On The Artificial Heart 58 

General News 

AMA President Annual Meeting Speaker 59 

Programs On Infection Control, Tumors 60 

16 Papers For April AAFP Meeting 62 

WVU Geriatric Program March 16 63 

Continuing Medical Education Activities 63 

Review A Book 64 

Winter Meeting Of Council 65 

An Open Letter 66 

AAFP Starts Memorial For Doctor Sleeth 67 

Special Departments 

WVU Medical Center News xvi 

Third-Party News, Views, Program Concerns xviii 

County Societies xxii 

Book Review xxiii 

Classified Section xxix 

Index To Advertisers xxx 


March, 1983, Vol. 79, No. 3 


Candidates for 

nutritional therapy... 


10 , 000,000 

alcoholics. Ethanol may 

produce many effects that 
together bring about nutritional 
deficiencies, so that alcoholism 
affects nutrition at many levels . 1 


25,500,000 geriatric 

patients. The older patient 
may have some disorder or socio- 
economic problem that can 
undermine good nutrition . 2 


23,500,000 surgical 

patients. Nutritional status 
can be compromised by the 
trauma of surgery; and some 
operations interfere with the 
ingestion, digestion and absorp- 
tion of food . 3 



Indications: Prophylactic or therapeutic 
nutritional supplementation in physio- 
logically stressful conditions, including 
conditions causing depletion, or reduced 
absorption or bioavailability of essential 
vitamins and minerals; certain conditions 
resulting from severe B-vitamin or ascor- 
bic acid deficiency; or conditions resulting 
in increased needs for essential vitamins 
and minerals. 

Contraindications: Hypersensitivity to 
any component. 

Warnings: Not for pernicious anemia or 
other megaloblastic anemias where vita- 
min Bii is deficient. Neurologic involve- 
ment may develop or progress, despite 
temporary remission of anemia, in patients 
with vitamin B ]2 deficiency who receive 
supplemental folic acid and who arc inade- 


Before prescribing, please consult com- 
plete product information, a summary of 
which follows: 

Each Berocca® Plus tablet contains 5000 IU 
vitamin A (as vitamin A acetate), 30 IU 
vitamin E (as d/-alpha tocophcryl acetate), 
500 mg vitamin C (ascorbic acid), 20 mg 
vitamin B, (as thiamine mononitrate), 

20 mg vitamin B 2 (riboflavin), 100 mg 
niacin (as niacinamide), 25 mg vitamin B„ 
(as pyridoxine IICl), 0.15 mg biotin, 25 mg 
pantothenic acid (as calcium pantothe- 
nate), 0.8 mg folic acid, 50 meg vitamin B, 2 
(cyanocobalamin), 27 mg iron (as ferrous 
fumaratc), 0.1 mg chromium (as chromium 
nitrate), 50 mg magnesium (as magnesium 
oxide), 5 mg manganese (as manganese 
dioxide), 3 mg copper (as cupric oxide), 
22.5 mg zinc (as zinc oxide). 


quately treated with B, 2 . 

Precautions: General: Certain conditions 
may require additional nutritional supple- 
mentation During pregnancy, supplemen- 
tation with vitamin D and calcium may be 
required. Not intended for treatment of 
severe specific deficiencies. Information 
for the Patient: Toxic reactions have been 
reported with injudicious use of certain 
vitamins and minerals. Urge patients to 
follow specific dosage instructions. Keep 
out of reach of children. Drug and Treat- 
ment Interactions: As little as 5 mg pyri- 
doxine daily can decrease the efficacy of 
lcvodopa in the treatment of parkinson- 
ism. Not recommended for patients 
undergoing such therapy. 

Adverse Reactions: Adverse reactions have 
been reported with specific vitamins and 


The Vest Virginia Medical Journal 

Official Publication of the West Virginia State Medical Association 

POST OFFICE BOX 1031 • CHARLESTON, W. VA. 25324 

Telephone (304) 346-0551 

© 1983, West Virginia State Medical Association 


EDITOR 

Stephen D. Ward, M. D. (1984) 
Wheeling 

MANAGING EDITOR AND 
BUSINESS MANAGER 
Mr. Charles R. Lewis 
Charleston 

EXECUTIVE ASSISTANT 
Mr. Custer B. Holliday 
Charleston 

ASSOCIATE EDITORS 
David Z. Morgan, M. D. (1983) 
Morgantown 

John M. Hartman, M. D. (1985) 
Charleston 

Vernon E. Duckwall, M. D. (1986) 
Elkins 

Thomas J. Holbrook, M. D. (1987) 
Huntington 

L. Walter Fix, M. D. (1988) 
Martinsburg 

Joe N. Jarrett, M. D. (1989) 

Oak Hill 


CONTENTS 


Scientific Articles 

Pain and Its Pharmacologic Manipulation — Charles 
D. Ponte, R.Ph., Pharm.D. 69 

Emergency Thyroidectomy For Tracheal Obstruc- 
tion — Romeo Y. Lim, M. D. 75 

Scientific Department 

Medical Grand Rounds From The West Virginia Uni- 
versity Medical Center iThe Noninvasive Diag- 
nosis of Coronary Artery Disease) — Edited by 
Irma H. Ullrich, M. D. 78 

The President's Page 

Ethics, Medicine and Society — Harry Shannon, M. D., 
President, W. Va. State Medical Association 84 


Published monthly by the West 
Virginia State Medical Association 
under the direction of the Publica- 
tion Committee. Original articles are 
accepted on condition that they are 
contributed solely to The Journal. 

Postmaster send form 3579 to 
The West Virginia Medical Journal, 
P. O. Box 1031, Charleston, WV 
25324. 

Entered as second-class matter 
January 1, 1926, at the post office 
at Charleston, West Virginia, under 
the act of March 3, 1879. 

Subscription Rates: $10 a year in 

the U.S.A.; $15 in foreign countries; 
$2 per single copy. Advertising rates 
furnished on request. Address all 
communications to Business Manager, 
The West Virginia Medical Journal, 
Box 1031, Charleston, West Virginia 
25324. Phone 346-0551. 

Microfilm editions beginning with 
the 1972 volume are available from 
University Microfilms, Inc., 300 N. 
Zeeb Road, Ann Arbor, Michigan 
48106. 

MEMBER, WEST VIRGINIA 
PRESS ASSOCIATION, 1983 

USPS 676 740 
ISSN 0043 • 3284 


Editorials 

Public Relations 85 

DRGs 85 

General News 

116th Annual Meeting 87 

Legislature Okays Hospital, Other Bills 88 

Continuing Education Activities 89 

Review A Book 90 

Act Freezes Hospital Rates 91 

Doctor Mufson Presents Paper in Norway 92 

Anesthesiologists to Meet June 3-4 92 

Collection Service Outlines Operation 93 

Child Abuse CME Program 94 

Special Departments 

WVU Medical Center News xiv 

Third-Party News, Views, Program Concerns xvi 

Obituaries xviii 

County Societies xix 

Classified Section xxvii 

Index To Advertisers xxviii 


April, 1983, Vol. 79, No. 4 



Roche salutes 

the history of West Virginia medicine 


THE FIRST STATE 
INSTITUTION WEST 
OF THE ALLEGHENIES 


Mental health care in West Virginia began in 1858 — 
before statehood— when the Virginia Assembly 
authorized construction of the first public institution 
west of the Alleghenies, at Weston. 1 

Completed by West Virginia, it opened in 1864 as 
the Trans-Allegheny Lunatic Asylum, consisting of three 
one-story buildings housing nine patients. The asylum 
was virtually the only tangible property West Virginia 
had to show for its share of the disputed Virginia debt 
of more than 13 million dollars at the end of the War 
Between the States. 1 


supplied the institution's kitchen.' To this day, Weston 
Hospital, as it is now known, maintains its own 
laundry, plumbing, maintenance and repair shops on 
spacious grounds. 2 

More important, it has served — and continues to 
serve — the mental health requirements of the people 
of West Virginia with the most advanced skills and 
sciences. In 1957, Weston reached a remarkable 
capacity of 2300 patients 2 — a far cry from the original 
nine — a tribute to the growth of this historically 
significant hospital. 



Copyright © 1983 by Roche Products Inc. All rights reserved 


A self-sufficient institution 


By 1880, the main building had grown to nine acres 
of floor space — a handsome gray stone structure said 
to be the largest hand-cut stone building in the 
country. Planned to be as self-sufficient as possible, 
the main building was set on a 350-acre farm that 


References: 1 . Writers' Program West Virginia A Guide to the Mountain State 
New York, Oxford University Press, 1956, p. 363. 2. Data on file, Hoffmann- 
La Roche Inc., Nutley, NJ. 


The West Virginia Medical Journal 

Official Publication of the West Virginia State Medical Association 

POST OFFICE BOX 1031 • CHARLESTON, W. VA. 25324 

Telephone (304) 346-0551 

© 1983, West Virginia State Medical Association 


EDITOR 

Stephen D. Ward, M. D. (1984) 
Wheeling 

MANAGING EDITOR AND 

BUSINESS MANAGER 

Mr. Charles R. Lewis 
Charleston 

EXECUTIVE ASSISTANT 

Mr. Custer B. Holliday 
Charleston 

ASSOCIATE EDITORS 

David Z. Morgan, M. D. (1983) 
Morgantown 

John M. Hartman, M. D. (1985) 
Charleston 

Vernon E. Duckwall, M. D. (1986) 
Elkins 

Thomas J. Holbrook, M. D. (1987) 
Huntington 

L. Walter Fix, M. D. (1988) 
Martinsburg 

Joe N. Jarrett, M. D. (1989) 

Oak Hill 


Published monthly by the West 
Virginia State Medical Association 
under the direction of the Publica- 
tion Committee. Original articles are 
accepted on condition that they are 
contributed solely to The Journal. 

Postmaster send form 3579 to 
The West Virginia Medical Journal, 
P. O. Box 1031, Charleston, WV 
25324. 

Entered as second-class matter 
January 1, 1926, at the post office 
at Charleston, West Virginia, under 
the act of March 3, 1879. 

Subscription Rates: $10 a year in 
the U.S.A.; $15 in foreign countries; 
$2 per single copy. Advertising rates 
furnished on request. Address all 
communications to Business Manager, 
The West Virginia Medical Journal, 
Box 1031, Charleston, West Virginia 
25324. Phone 346-0551. 

Microfilm editions beginning with 
the 1972 volume are available from 
University Microfilms, Inc., 300 N. 
Zeeb Road, Ann Arbor, Michigan 
48106. 

MEMBER, WEST VIRGINIA 
PRESS ASSOCIATION, 1983 

USPS 676 740 
ISSN 0043 - 3284 


CONTENTS 

Scientific Articles 

Hypokalemic Myopathy In Hyperemesis Gravi- 
darum: Its Historical Significance — Jack E. 

Riggs, M. D.; Robert C. Griggs, M. D.; and Ludwig 


Gutmann, M. D. 95 

Diagnosis And Treatment Of Alzheimer’s Disease — 

M. K. II asan, M. D.; Nancy L. Slack, A.C.S.W.; and 
Roger P. Mooney, M. A. 98 

The President’s Page 

The ‘Cost Containment’ (?) Bill — Harry Shannon, 

M. D., President. W. Va. State Medical Association 104 

Editorials 

More On DRGs 105 

The Patient, Or The System? 105 

General News 

FMG Group President Convention Keynoter 107 

Continuing Education Activities 108 

Wildwater Medical-Surgical Conference 109 

Group Endorses Insanity Defense 110 

Review A Book 110 

Residencies For MU Graduates Announced 111 

Majority of WVU Grads Choose Primary Care 111 

New Patient Record Law Effective in June 112 

Spring Meeting of Council 113 

Special Departments 

WVU Medical Center News xvi 

Third-Party News, Views, Program Concerns xviii 

Obituaries xx 

County Societies xxiii 

Classified Section xxix 

Index To Advertisers xxx 


May, 1983, Vol. 79, No. 5 


v 


THE ARMY NEEDS 
PHYSICIANS 
PART-TIME. 

The Army Reserve offers you an excellent 
opportunity to serve your country as a physician and 
a commissioned officer in the Army Reserve Medical 
Corps. Your time commitment is flexible, so it can fit 
into your busy schedule. You will work on medical 
projects right in your community. In return, you will 
complement your career by working and consulting 
with top physicians during monthly Reserve meetings 
and medical conferences. You will enjoy the benefits 
of officer status, including a nomcontributory retirement 
annuity when you retire from the Army Reserve, 
as well as funded continuing medical education pro- 
grams. A small investment of your time is all it takes 
to make a valuable medical contribution to your com- 
munity and country. For more information, simply 
call the number below. 

ARMY RESERVE. 
BE ALL YOU CAN BE. 


Southern West Virginia 

MAJ. Sheila T. Bowman, ANC 

USAR AMEDD Procurement 

Forest Glen Section 

Walter Reed Army Medical Center 

Washington, DC 20307 

(301) 427-5101/5131 


Northern West Virginia 

MAJ. James E. Kuza, MSC 
USAR AMEDD Procurement 
Federal Building, Room 304 
1 000 Liberty Avenue 
Pittsburgh, PA 15222 
(412) 391-2279/2289 


The Vest Vinpia flcdical Journal 

Official Publication of the West Virginia State Medical Association 

POST OFFICE BOX 1031 • CHARLESTON, W. VA. 25324 

Telephone (304) 346-0551 

© 1983, West Virginia State Medical Association 


EDITOR 

Stephen D. Ward, M. D. (1984) 
Wheeling 

MANAGING EDITOR AND 
BUSINESS MANAGER 
Mr. Charles R. Lewis 
Charleston 

EXECUTIVE ASSISTANT 
Mr. Custer B. Holliday 
Charleston 

ASSOCIATE EDITORS 
David Z. Morgan, M. D. (1983) 
Morgantown 

John M. Hartman, M. D. (1985) 
Charleston 

Vernon E. Duckwall, M. D. (1986) 
Elkins 

Thomas J. Holbrook, M. D. (1987) 
Huntington 

L. Walter Fix, M. D. (1988) 
Martinsburg 

Joe N. Jarrett, M. D. (1989) 

Oak Hill 


Published monthly by the West 
Virginia State Medical Association 
under the direction of the Publica- 
tion Committee. Original articles are 
accepted on condition that they are 
contributed solely to The Journal. 

Postmaster send form 3579 to 
The West Virginia Medical Journal, 
P. O. Box 1031, Charleston, WV 
25324. 

Entered as second-class matter 
January 1, 1926, at the post office 
at Charleston, West Virginia, under 
the act of March 3, 1879. 

Subscription Rates: $10 a year in 
the U.S.A.; $15 in foreign countries; 
$2 per single copy. Advertising rates 
furnished on request. Address all 
communications to Business Manager, 
The West Virginia Medical Journal, 
Box 1031, Charleston, West Virginia 
25324. Phone 346-0551. 

Microfilm editions beginning with 
the 1972 volume are available from 
University Microfilms, Inc., 300 N. 
Zeeb Road, Ann Arbor, Michigan 
48106. 


CONTENTS 


Scientific Articles 

Value and Limitations of the Noninvasive Labora- 
tory: Experience With Over 5,000 Patients — Ali 
F. AbuRahma, M. D.; and Linda Osborne, L.P.N. 139 

Tuberculosis After Jejunoileal Bypass Surgery — 
Leeman P. Maxwell, M. D.; Rashida A. Khakoo, M. D.; 
and Edwin J. Morgan, M. D. 147 

The President’s Page 

The Role of Our Organization — Harry Shannon, 


M. D.. President, W. \ a. State Medical Association 150 

Editorials 

Quality Commitment 151 

New Resources 152 

Single Issue 152 

General News 

Cardiovascular Disease Convention Topic 153 

Saturday Convention Dinner Added 154 

Continuing Education Activities 155 

Cancer Reference Manual Offered 156 

Association Names Scholarship Winners 157 

Special Departments 

WVU Medical Center News xvi 

Third-Party News, Views, Program Concerns xviii 

Obituaries xix 

County Societies xix 


MEMBER, WEST VIRGINIA 1982 ANNUAL AUDIT xxii 

PRESS ASSOCIATION, 1983 

Classified Section xxv 

USPS 676 740 

ISSN 0043 - 3284 INDEX To ADVERTISERS XXvi 


July, 1983, Vol. 79, No. 7 


v 



Roche salutes 

the history of West Virginia medicine 


THE FIRST STATE 
INSTITUTION WEST 
OF THE ALLEGHENIES 


Mental health care in West Virginia began in 1858 — 
before statehood-— when the Virginia Assembly 
authorized construction of the first public institution 
west of the Alleghenies, at Weston. 1 

Completed by West Virginia, it opened in 1864 as 
the Trans-Allegheny Lunatic Asylum, consisting of three 
one-story buildings housing nine patients. The asylum 
was virtually the only tangible property West Virginia 
had to show for its share of the disputed Virginia debt 
of more than 13 million dollars at the end of the War 
Between the States. 1 


supplied the institution's kitchen. 1 To this day, Weston 
Hospital, as it is now known, maintains its own 
laundry, plumbing, maintenance and repair shops on 
spacious grounds. 2 

More important, it has served — and continues to 
serve — the mental health requirements of the people 
of West Virginia with the most advanced skills and 
sciences. In 1957, Weston reached a remarkable 
capacity of 2300 patients 2 — a far cry from the original 
nine — a tribute to the growth of this historically 
significant hospital. 



A self-sufficient institution 

By 1880, the main building had grown to nine acres 
of floor space — a handsome gray stone structure said 
to be the largest hand-cut stone building in the 
country. Planned to be as self-sufficient as possible, 
the main building was set on a 350-acre farm that 


References: 1. Writers' Program West Virginia A Guide to the Mountain State 
New York, Oxford University Press, 1956. p 363 2. Data on file, Hoffmann- 
La Roche Inc , Nutley, NJ 


Copyright © 1983 by Roche Products Inc All rights reserved 



The Vest Virginia Tledical Journal 

Official Publication of the West Virginia State Medical Association 

POST OFFICE BOX 1031 • CHARLESTON, W. VA. 25324 

Telephone (304) 346-0551 

© 1983, West Virginia State Medical Association 


EDITOR 

Stephen D. Ward, M. D. (1984) 
Wheeling 

MANAGING EDITOR AND 
BUSINESS MANAGER 
Mr. Charles R. Lewis 
Charleston 

EXECUTIVE ASSISTANT 
Mr. Custer B. Holliday 
Charleston 

ASSOCIATE EDITORS 
David Z. Morgan, M. D. (1983) 
Morgantown 

John M. Hartman, M. D. (1985) 
Charleston 

Vernon E. Duckwall, M. D. (1986) 
Elkins 

Thomas J. Holbrook, M. D. (1987) 
Huntington 

L. Walter Fix, M. D. (1988) 
Martinsburg 

Joe N. Jarrett, M. D. (1989) 

Oak Hill 


CONTENTS 


Scientific Articles 

Effect of Ethrane Supplementation on Intra- 

PULMONARY SHUNTING IN DOGS ANESTHETIZED WlTH 


Nitrous Oxide and Morphine — David F. Graf, 

M. D.; and Lawrence M. Lavine, M. D. 159 

Dopamine-Modulating Drugs, Amenorrhea-Galactor- 
rhea and Neuropsychiatric Illnesses — Paul E. 
Frye, M. D. 161 

The President’s Page 

Hanging Together — Harry Shannon, M. D.. President, 

W. Va. State Medical Association 166 

Editorials 

Positive Year 167 

Public Trust 168 


Published monthly by the West 
Virginia State Medical Association 
under the direction of the Publica- 
tion Committee. Original articles are 
accepted on condition that they are 
contributed solely to The Journal. 

Postmaster send form 3579 to 
The West Virginia Medical Journal, 
P. O. Box 1031, Charleston, WV 
25324. 

Entered as second-class matter 
January 1, 1926, at the post office 
at Charleston, West Virginia, under 
the act of March 3, 1879. 

Subscription Rates: $10 a year in 
the U.S.A.; $15 in foreign countries; 
$2 per single copy. Advertising rates 
furnished on request. Address all 
communications to Business Manager, 
The West Virginia Medical Journal, 
Box 1031, Charleston, West Virginia 
25324. Phone 346-0551. 

Microfilm editions beginning with 
the 1972 volume are available from 
University Microfilms, Inc., 300 N. 
Zeeb Road, Ann Arbor, Michigan 
48106. 

MEMBER, WEST VIRGINIA 
PRESS ASSOCIATION, 1983 

USPS 676 740 
ISSN 0043 - 3284 


General News 

116th Annual Meeting 169 

Continuing Education Activities 171 

New Association Members 173 

Review A Book 174 

Auxiliary Completes Meeting Plans 175 

Doctor Fix Heads State Presidents Group 175 

Convention Program 177 

A Word of Thanks 180 

Delegates and Alternates 181 

Auxiliary Program 183 

Scientific Exhibits 185 

Annual Reports 188 

Special Departments 

WVU Medical Center News xii 

Third-Party News, Views, Program Concerns xiv 

Obituaries xv 

County Societies xv 

Classified Section xxi 

Index To Advertisers xxii 


August, 1983, Vol. 79, No. 8 


THE ARMY NEEDS 
PHYSICIANS 
PART-TIME. 

The Army Reserve offers you an excellent 
opportunity to serve your country as a physician and 
a commissioned officer in the Army Reserve Medical 
Corps. Your time commitment is flexible, so it can fit 
into your busy schedule. You will work on medical 
projects right in your community. In return, you will 
complement your career by working and consulting 
with top physicians during monthly Reserve meetings 
and medical conferences. You will enjoy the benefits 
of officer status, including a non-contributory retirement 
annuity when you retire from the Army Reserve, 
as well as funded continuing medical education pro- 
grams. A small investment of your time is all it takes 
to make a valuable medical contribution to your com- 
munity and country. For more information, simply 
call the number below. 

ARMY RESERVE. 
BE ALL YOU CAN BE. 


Southern West Virginia Northern West Virginia 

MAJ. Sheila T. Bowman, ANC MAJ. James E. Kuza, MSC 

USAR AMEDD Procurement USAR AMEDD Procurement 

Forest Glen Section Federal Building, Room 304 

Walter Reed Army Medical Center 1000 Liberty Avenue 

Washington, DC 20307 Pittsburgh, PA 15222 

(301) 427-5101/5131 (412) 391-2279/2289 


The Vest Virginia ricdical Journal 

Official Publication of the West Virginia State Medical Association' 

POST OFFICE BOX 1031 • CHARLESTON, W. VA. 25324 

Telephone (304) 346-0551 

© 1983, West Virginia State Medical Association 


EDITOR 

Stephen D. Ward, M. D. (1984) 
Wheeling 

MANAGING EDITOR AND 
BUSINESS MANAGER 
Mr. Charles R. Lewis 
Charleston 

EXECUTIVE ASSISTANT 
Mr. Custer B. Holliday 
Charleston 

ASSOCIATE EDITORS 
David Z. Morgan, M. D. (1983) 
Morgantown 

John M. Hartman, M. D. (1985) 
Charleston 

Vernon E. Duckwall, M. D. (1986) 
Elkins 

Thomas J. Holbrook, M. D. (1987) 
Huntington 

L. Walter Fix, M. D. (1988) 
Martinsburg 

Joe N. Jarrett, M. D. (1989) 

Oak Hill 


CONTENTS 


Scientific Articles 

Public Health Legacy of the Vietnam War: Post- 
Traumatic Stress Disorder and Implications for 


Appalachians — Daniel Sumrok, B. A.; Steven L. 
Giles, Ph.D.; and Mildred Mitchell-Bateman, M. D. 191 

Practical Tips on Adverse Drug Effects in Glau- 
coma Therapy — Larry T. Schwab, M. D. 199 

The President’s Page 

Strategy For Change — Carl R. Adkins, M. D., Presi- 
dent, W. Va. State Medical Association 202 

Editorials 

DRG Concerns 203 

Child Safety 203 

Successful Cost Control Provider-Motivated 204 

‘Positive Futurist’ 204 


Published monthly by the West 
Virginia State Medical Association 
under the direction of the Publica- 
tion Committee. Original articles are 
accepted on condition that they are 
contributed solely to The Journal. 

Postmaster send form 3579 to 
The West Virginia Medical Journal, 
P. O. Box 1031, Charleston, WV 
25324. 

Entered as second-class matter 
January 1, 1926, at the post office 
at Charleston, West Virginia, under 
the act of March 3, 1879. 

Subscription Rates: $10 a year in 
the U.S.A.; $15 in foreign countries; 
$2 per single copy. Advertising rates 
furnished on request. Address all 
communications to Business Manager, 
The West Virginia Medical Journal, 
Box 1031, Charleston, West Virginia 
25324. Phone 346-0551. 

Microfilm editions beginning with 
the 1972 volume are available from 
University Microfilms, Inc., 300 N. 
Zeeb Road, Ann Arbor, Michigan 
48106. 

MEMBER, WEST VIRGINIA 
PRESS ASSOCIATION, 1983 

USPS 676 740 
ISSN 0043 - 3284 


General News 

Mid-Winter Conference Lineup 205 

New Marshall Class Has 48 Students 206 

Hal Wanger Family Practice Program 206 

Hypertension Program September 14 208 

Group Management Meeting in September 208 

Health Care Coverage Urged For Jobless 209 

New WVU Charleston Division Staff Members 209 
Hospital Reps Meet With AMA Council 210 

New WVU Class of 88 Announced 211 

MU Surgery, Educational Skills Programs 212 

Gastroenterology Update October 5 213 

State Money Woes Hit Medical Services 213 

Doctors’ Medicaid Pay Public Information 214 

Special Departments 

WVU Medical Center News xviii 

Third-Party News, Views, Program Concerns xx 

Obituaries xxi 

Classified Section xxix 

Index To Advertisers xxx 


September, 1983, Vol. 79, No. 9 


v 



Roche salutes 

the history of West Virginia medicine 


THE FIRST STATE 
INSTITUTION WEST 
OF THE ALLEGHENIES 




Mental health care in West Virginia began in 1858 — 
before statehood — when the Virginia Assembly 
authorized construction of the first public institution 
west of the Alleghenies, at Weston. 1 

Completed by West Virginia, it opened in 1864 as 
the Trans-Allegheny Lunatic Asylum, consisting of three 
one-story buildings housing nine patients. The asylum 
was virtually the only tangible property West Virginia 
had to show for its share of the disputed Virginia debt 
of more than 13 million dollars at the end of the War 
Between the States. 1 


supplied the institution's kitchen. 1 To this day, Weston 
Hospital, as it is now known, maintains its own 
laundry, plumbing, maintenance and repair shops on 
spacious grounds. 2 

More important, it has served — and continues to 
serve — the mental health requirements of the people 
of West Virginia with the most advanced skills and 
sciences. In 1957, Weston reached a remarkable 
capacity of 2300 patients 2 — a far cry from the original 
nine — a tribute to the growth of this historically 
significant hospital. 


A self-sufficient institution 

By 1880, the main building had grown to nine acres 
of floor space — a handsome gray stone structure said 
to be the largest hand-cut stone building in the 
country. Planned to be as self-sufficient as possible, 
the main building was set on a 350-acre farm that 


References: 1. Writers' Program West Virginia A Guide to the Mountain State 
New York, Oxford University Press, 1956, p 363 2. Data on tile, Hoffmann- 
La Roche Inc , Nutley. NJ 



Copyright © 1983 by Roche Products Inc All rights reserved 



The West Virginia Hectical Journal 

Official Publication of the West Virginia State Medical Association 

POST OFFICE BOX 1031 • CHARLESTON, W. VA. 25324 

Telephone (304) 346-0551 

© 1983, West Virginia State Medical Association 


EDITOR 

Stephen D. Ward, M. D. (1984) 
Wheeling 

AAANAGING EDITOR AND 
BUSINESS AAANAGER 
AAr. Charles R. Lewis 
Charleston 

EXECUTIVE ASSISTANT 
AAr. Custer B. Holliday 
Charleston 

ASSOCIATE EDITORS 
David Z. AAorgan, AA. D. (1983) 
AAorgantown 

John AA. Hartman, AA. D. (1985) 
Charleston 

Vernon E. Duckwall, AA. D. (1986) 
Elkins 

Thomas J. Holbrook, AA. D. (1987) 
Huntington 

L. Walter Fix, AA. D. (1988) 
AAartinsburg 

Joe N. Jarrett, AA. D. (1989) 

Oak Hill 


Published monthly by the West 
Virginia State AAedical Association 
under the direction of the Publica- 
tion Committee. Original articles are 
accepted on condition that they are 
contributed solely to The Journal. 

Postmaster send form 3579 to 
The West Virginia AAedical Journal, 
P. O. Box 1031, Charleston, WV 
25324. 

Entered as second-class matter 
January 1, 1926, at the post office 
at Charleston, West Virginia, under 
the act of AAarch 3, 1879. 

Subscription Rates: $10 a year in 
the U.S.A.; $15 in foreign countries; 
$2 per single copy. Advertising rates 
furnished on request. Address all 
communications to Business AAanager, 
The West Virginia AAedical Journal, 
Box 1031, Charleston, West Virginia 
25324. Phone 346-0551. 

AAicrofilm editions beginning with 
the 1972 volume are available from 
University AAicrofilms, Inc., 300 N. 
Zeeb Road, Ann Arbor, AAichigan 
48106. 

MEMBER, WEST VIRGINIA 
PRESS ASSOCIATION, 1983 

USPS 676 740 
ISSN 0043 - 3284 


CONTENTS 


Scientific Articles 

Carbon Dioxide Laser in Otolaryngology: Head and 


Neck Surgery — Romeo Y. Lim, M. D. 215 

Sonographic Antepartum Diagnosis of Dicephalus 
Dipus Dibrachius: Two Case Reports — Katrina J. 
Garten, RDMS; K. F. Rawlinson, M. D.; and Robert 
P. Pulliam, M. D. 218 

Scientific Department 

Medical Grand Rounds From the West Virginia Uni- 
versity Medical Center (Osteoporosis) — Edited 
by Irma H. Ullrich, M. D. 221 

The President’s Page 

A Time For Action — Carl R. Adkins, M. D., President, 

W. Va. State Medical Association 228 

Editorials 

Work To Be Done 229 

The Public Factor 230 

Concern For Quality 230 

General News 

Dr. Carl R. Adkins Assumes Presidency 231 

Doctor Holroyd Named To Honorary AMA Post 232 

Membership Amendments Adopted 233 

17th Mid-Winter Clinical Conference 236 

Mrs. T. Keith Edwards Heads Auxiliary 239 

Association Has Heavy Workload 240 

Doctor Adkins: ‘Strategy For Change’ 241 

Medical Program Payments On Schedule 242 

Special Departments 

WVU Medical Center News xviii 

Third-Party News, Views, Program Concerns xx 

Obituaries xxiii 

Necrology Report xxvi 

Resolutions xxvii 

Classified Section xxxiii 

Index To Advertisers xxxiv 


October, 1983, Vol. 79, No. 10 



Prescribed 

For 

Security 

Sound coverage begins with a 
sound carrier. As a specialist in 
professional liability insurance, 

ICA has earned its enviable 
performance record through 
selective underwriting and 
unexcelled claims defense. This 
solid record of achievement has 
enabled ICA to successfully expand 
to over 30 states across the nation. 

Our comprehensive, affordable 
coverage is designed to eliminate 
headaches and unnecessary 
expenses. For professional liability 
insurance with no side effects, 
contact: Insurance Corporation of 
America, ICA Center, 4295 San 
Felipe, P.O. Box 56308, Houston, 
Texas 77256. Phone 1-800-231-2615; 
in Texas call 1-800-392-9702. 

K/l 

The Specialist in Professional 
Liability Insurance. 



The West Virginia Medical Journal 

Official Publication of the West Virginia State Medical Association 

POST OFFICE BOX 1031 • CHARLESTON, W. VA. 25324 

Telephone (304) 346-0551 

© 1983, West Virginia State Medical Association 


EDITOR 

Stephen D. Ward, M. D. (1984) 
Wheeling 

MANAGING EDITOR AND 
BUSINESS MANAGER 
Mr. Charles R. Lewis 
Charleston 

EXECUTIVE ASSISTANT 
Mr. Custer B. Holliday 
Charleston 


CONTENTS 


Scientific Articles 

Limb Preservation in Extremity Osteosarcoma — 

Eric T. Jones, M. D.. Ph.D.; and J. David Blaha, M. D. 265 

1983 Van Liere Memorial Student Research Con- 
vocation, WVU School of Medicine 270 


ASSOCIATE EDITORS 

David Z. Morgan, M. D. (1983) 
Morgantown 

John M. Hartman, M. D. (1985) 
Charleston 

Vernon E. Duckwall, M. D. (1986) 
Elkins 

Thomas J. Holbrook, M. D. (1987) 
Huntington 

L. Walter Fix, M. D. (1988) 
Martinsburg 

Joe N. Jarrett, M. D. (1989) 

Oak Hill 


Published monthly by the West 
Virginia State Medical Association 
under the direction of the Publica- 
tion Committee. Original articles are 
accepted on condition that they are 
contributed solely to The Journal. 

Postmaster send form 3579 to 
The West Virginia Medical Journal, 
P. O. Box 1031, Charleston, WV 
25324. 

Entered as second-class matter 
January 1, 1926, at ^the post office 
at Charleston, West Virginia, under 
the act of March 3, 1879. 

Subscription Rates: $10 a year in 

the U.S.A.; $15 in foreign countries; 
$2 per single copy. Advertising rates 
furnished on request. Address all 
communications to Business Manager, 
The West Virginia Medical Journal, 
Box 1031, Charleston, West Virginia 
25324. Phone 346-0551. 

Microfilm editions beginning with 
the 1972 volume are available from 
University Microfilms, Inc., 300 N. 
Zeeb Road, Ann Arbor, Michigan 
48106. 

MEMBER, WEST VIRGINIA 
PRESS ASSOCIATION, 1983 

USPS 676 740 
ISSN 0043 - 3284 


Scientific Department 

Medical Grand Rounds From The West Virginia Uni- 
versity Medical Center (Drug Use in The 


Elderly) — Edited by Irma H. Ullrich, M. D. 275 

The President’s Page 

The Myth of Medicare — Carl R. Adkins, M. D., Presi- 
dent, W. Va. State Medical Association 280 

Editorials 

Unique Assignment 281 

Other Forces 281 

Communications 282 

General News 

Conference Panelists, Speaker on Disability 283 

Review A Book 285 

Continuing Education Activities 286 

MCI Announces Sports Medicine Conference 286 

Self-Assessment Computer Courses 288 

Special Departments 

WVU Medical Center News xiv 

Third-Party News, Views, Program Concerns xvi 

Obituaries xviii 

County Societies xxi 

Book Review xxiv 

1983 Annual Index xxvii 

Classified Section xxix 

Index To Advertisers xxx 


December, 1983, Vol. 79, No. 12 


v 



Prescribed 

For 

Security 

Sound coverage begins with a 
sound carrier. As a specialist in 
professional liability insurance, 

ICA has earned its enviable 
performance record through 
selective underwriting and 
unexcelled claims defense. This 
solid record of achievement has 
enabled ICA to successfully expand 
to over 30 states across the nation. 

Our comprehensive, affordable 
coverage is designed to eliminate 
headaches and unnecessary 
expenses. For professional liability 
insurance with no side effects, 
contact: Insurance Corporation of 
America, ICA Center, 4295 San 
Felipe, P.O. Box 56308, Houston, 
Texas 77256. Phone 1-800-231-2615; 
in Texas call 1-800-392-9702. 


IOV 

The Specialist in Professional 
Liability Insurance. 


The West VirgiDia ttedical Journal 

Vol. 79, No. 1 January, 1983 



Postmastectomy Breast Reconstruction* 


GEORGE B. IRONS, M. D. 

Section of Plastic and Reconstructive Surgery, Mayo 
Clinic and Mayo Foundation, Rochester, Minnesota 


Postmastectomy breast reconstruction is ap- 
propriate and worthwhile for any patient with a 
good prognosis who strongly desires reconstruc- 
tion. With the several techniques available, 
reasonably good results generally can be obtain- 
ed. Examples of those various techniques are 
presented, discussed and illustrated. 

T^ACH year in the United States approximately 
100,000 women are diagnosed as having 
breast cancer. Most of these women will be 
treated surgically. The resultant deformity is a 
heavy burden for these women to bear the rest 
of their lives. In the past, their options have 
been either to do nothing or to wear an external 
prosthesis. More recently, a third option, which 
is more acceptable to many women, is surgical 
breast reconstruction. 

Breast reconstruction, owing to a number of 
factors, has become more accepted. First, the 
ablative surgery has become less radical because 
the disease is diagnosed at an earlier stage than 
previously: and, with proper case selection, the 
results with preservation of the pectoral muscles 
and enough skin for closure are as good as they 
are with radical removal of these structures. Ad- 
junctive irradiation and chemotherapy have 
improved the survival of patients with cancers 
of stages II and higher. 

Second, technical progress in breast recon- 
struction now permits reconstruction in almost 

“Presented at the William E. Irons, M. D., Surgical 
Symposium, Marshall University School of Medicine, 
Huntington, West Virginia, September 8, 1980. 


any patient with an acceptable result. With the 
development of silicone prostheses and the de- 
sign of new flaps, the reconstructive procedure 
has become less complicated, and the results 
are more acceptable. 

Third, patient awareness and acceptance of 
breast reconstruction is increasing. As one pa- 
tient said. “The mastectomy may have saved my 
life, but the reconstruction made it worth living.” 
The woman who has undergone reconstruction 
feels more feminine and more secure socially 
and sexually. 

The advantages of breast reconstruction are 
that the reconstructed breast is incorporated in 
the bodv image whereas the external prosthesis 
is not, clothes are easier to fit, and there is more 
freedom of movement without fear of dislodg- 
ment of an external prosthesis. 

Indications 

Almost any patient with a favorable prognosis 
who desires breast reconstruction and who is 
an acceptable operative risk is a candidate for 
reconstruction. The main considerations are the 
pathology of the tumor, the treatment given, and 
the time interval since treatment. The pathology 
is important because reconstruction generally 
should be undertaken only in the patient who 
has a good prognosis, that is, one who has stage 
I disease or stage II disease with three or less 
positive low axillary nodes. 

The patient should have had adequate treat- 
ment and, if irradiation or chemotherapy is 
being used as an adjunct to surgery, reconstruc- 
tion should be delayed until this treatment is 
completed. 


January, 1983, Vol. 79, No. 1 


1 


The timing of reconstruction requires two con- 
siderations: the time when the tissues in the 

mastectomy area will be healed enough for re- 
construction, and the length of time one should 
watch for recurrence before proceeding with 
reconstruction. While reconstruction can be 
done any time after mastectomy, most surgeons 
desire to wait until the wound is well-healed and 
the scars have matured, about six months after 
mastectomy. In regard to the length of time one 
should watch for recurrence before proceeding 
with reconstruction, obviously, the longer one 
waits the better. Most recurrences are noted 
during the first two years. Many patients, how- 
ever, do not want to wait that long before 
reconstruction and, since the incidence of local 
recurrence is low for stage I disease, reconstruc- 
tion can proceed as soon as the tissues are suit- 
able. 

Essentials of Breast Reconstruction 

Thorough Analysis of the Patient : The history 
should include the tumor pathology, extent of 
spread and treatment given. The mastectomy 
side should be examined for any residual disease 
and for suppleness of the skin, scar and pectoral 
muscle. The other breast should be examined 
for breast disease, and its size and shape should 



Figure 1. A. After modified radical right mas- 
tectomy. B. After reconstruction on right side using 
available tissue and submuscular silicone implant. 
Subcutaneous mastectomy and submuscular implant 
were performed on left side. 


be noted. A thorough analysis of the patient and 
her disease helps determine whether she is a 
candidate for breast reconstruction and the 
method that is most appropriate. 

Careful Planning and Execution: After de- 

termining the anatomic situation in a given pa- 
tient, the surgeon should discuss the options for 
reconstruction. This discussion always involves 
reconstructing a breast mound on the mastectomy 
side. Reconstruction also may involve a nipple- 
areolar complex, infraclavicular fullness, or an- 
terior axillary fold, depending on what tissues 
have been removed and what the patient wants 
replaced. The other breast should be considered 
at the same time because the most important 
anatomic goal is symmetry; frequently, the other 
breast will have to be reshaped to match the 
reconstructed breast. Also, the possibility of 
cancer developing in the other breast is a con- 
cern to most patients. It should be assumed 
that whatever factors were responsible for the 
cancer in one breast are still operating against 
the second breast. 

Other factors are the pathology of the cancer, 
family history, and the presence of disease in 
the other breast. Lobular carcinoma has a 30- 
per cent incidence of bilaterality. If the patient’s 



Figure 2. A. After modified radical left mastec- 
tomy. B. After reconstruction using a thoraco- 
epigastric flap and submuscular silicone implant on 
the left and subcutaneous mastectomy and sub- 
muscular implant on the right. 


2 


The West Virginia Medical Journal 



Figure 3. A. After modified radical mastectomy 
on the right. B. After reconstruction using latis- 
simus dorsi myocutaneous flap and silicone implant 
on the right. 


mother had breast cancer, the risk is doubled. 
If the other breast has disease such as duct 
epithelial hyperplasia, bloody nipple discharge, 
or extensive fibrocystic disease, the risk of can- 
cer is increased. In these situations, subcutane- 
ous mastectomy of the remaining breast should 
be considered. 

After both sides have been evaluated and the 
options discussed with the patient, the method 
of reconstruction can be determined. A success- 
ful outcome depends on whether the patient 
understands what can and cannot be accomplish- 
ed by the operation. Various methods of recon- 
struction can be used, but generally, the method 
should he the simplest and safest one that will 
give an acceptable result. The breast mound is 
replaced by a silicone prosthesis. This must be 
covered by healthy skin and. preferably, by 
healthy muscle. If the pectoralis muscle is 
present and the skin is adequate, the simplest 
method of reconstruction is the creation of a 
submuscular pocket into which a silicone pros- 
thesis is placed I Figure 1). 

If muscle or skin is not available and ade- 
quate, then cover for the prosthesis will have to 
be provided by a flap. The possibilities are the 
thoraco-epigastric flap, 1,2 which can provide 



Figure 4. A. After right radical mastectomy. B. 
After reconstruction using omentum and skin graft 
to cover silicone implant. 


skin (Figure 2); the latissimus dorsi flap, 3 ' 5 
which can provide skin and muscle (Figure 3); 
and the omentum, 6 which can provide cover that 
will accept a skin graft (Figure 4). The latis- 
simus dorsi flap is the most versatile and de- 
pendable and. consequently, is the most fre- 
quently used method for supplying soft-tissue 
replacement. 

After the mastectomized side has been recon- 
structed, attention is then directed to the other 
side. In some cases, nothing may be required. 
More often, though, a mastopexy, reduction 
mastectomy, or subcutaneous mastectomy will be 
necessary. Again, one should strive for as much 
symmetry as possible. The main determinants 
of symmetry are size, shape and position of the 
inframammary lines. 

Construction of a nipple-areola should be de- 
ferred until after the wounds are well-healed 
and the tissues have settled in place; this usually 
requires 10 to 12 weeks. One can then best 
determine the proper location for the nipple- 
areola. Various methods have been employed 
for this, hut the best results have been obtained 
by a method that utilizes similar tissues for each 
side. One can make two areolae from one intact 
areola (Figure 5), or one can transfer medial 


January, 1983, Vol. 79, No. 1 


3 


thigh skin to the breast as a skin graft (Figure 
6). For the nipple, a graft from the intact nip- 
ple can be used, or if there is no intact nipple, 
labia minora tissue can be used for both sides. 

Follow-Up and Revisions : For optimal results, 
the surgeon and the patient must be willing to 



Figure 5. Reconstructed nipple-areoia on left 
using shared tissue from normal right side. 



Figure 6. Reconstructed nipple areola using 
medial thigh skin for areola and free graft from 
opposite nipple. 


follow up the surgery with periodic evaluations. 
For most patients, minor adjustments or re- 
visions of the reconstruction need to be made. 
In many, these revisions may be done at the 
same time as the nipple-areolar construction. 

Complications 

The potential complications of these pro- 
cedures should be discussed with every patient 
before operation. Postoperative bleeding and in- 
fection may occur after any surgery. Necrosis 
of skin flaps, implant extrusion, and capsule 
contracture are possible hazards with breast re- 
construction, although they are not common, 
especially if the prosthesis is placed submuscu- 
larly. There is a possibility that reconstruction 
can cover up local recurrence; however, when 
the prosthesis is placed behind skin, sub- 
cutaneous tissue and muscle, recurrence in these 
tissues is easily palpable. 

References 

1. Tai Y, Hasegawa H: A transverse abdominal flap 
for reconstruction after radical operations for recurrent 
breast cancer. Plast Reconstr Surg 1974; 53:52-54. 

2. Cronin TD, Upton J, McDonough JM: Recon- 

struction of the breast after mastectomy. Plast Reconstr 
Surg 1977; 59:1-14. 

3. Olivari N: The latissimus flap. Br J Plast Surg 
1976; 29:126-128. 

4. Bostwick J III, Vasconez LO, Jurkiewicz MJ: 
Breast reconstruction after a radical mastectomy. Plast 
Reconstr Surg 1978; 61:682-693. 

5. Maxwell GP, McGibbon BM, Houpes JE: Vas- 
cular considerations in the use of a latissimus dorsi 
myocutaneous flap after a mastectomy with an axillary 
dissection. Plast Reconstr Surg 1979; 64:771-780. 

6. Arnold PG, Hartrampf CR, Jurkiewicz MJ: One- 

stage reconstruction of the breast, using the transposed 
greater omentum: Case report. Plast Reconstr Surg 

1976; 57:520-522. 


4 


The West Virginia Medical Journal 



Popliteal Vascular Trauma In Skiers 


WALTER B. BLUM, M. D. 
ROBERT A. ROSE, M. D. 
Elkins, West Virginia 


During the ivinter of 1980 and 1981, two 
cases of popliteal vascular trauma incurred by 
skiers were treated at the Memorial General 
Hospital in Elkins, West Virginia. These two 
cases are reported with particular attention to 
the management of these complex injuries. 

V/Tost reported traumatic injuries to the popli- 
teal artery in a civilian setting occur from 
penetrating wounds due to single, low-velocity 
missiles. A significant number of popliteal 
arterial injuries also result from blunt trauma, 
usually caused by motor vehicle accidents. 1 This 
is a report of two cases of popliteal vascular 
trauma associated with injuries to the knee in- 
curred while skiing. 

Case One 

A 21-year-old white female sustained blunt 
trauma to the right knee while skiing. On ad- 
mission to the hospital, the right lower extremity 
was grossly deformed. The right popliteal pulse 
was absent, as were the right dorsalis pedis and 
posterior tibial pulses. The patient was taken 
promptly to the operating room where operative 
arteriography documented an obstruction of flow 
at the mid-popliteal artery level. The popliteal 
space was explored through a posterior “S”- 
shaped incision, with the patient positioned in 
the prone position on the operating room table. 
A large hematoma was evacuated from the 
popliteal space. The gastrocnemius and plantaris 
muscles were noted to have been avulsed from 
their origins. The popliteal artery was noted to 
be crushed for a one and one-half inch segment 
near the mid-portion of its passage through the 
popliteal space. 

A primary repair of the injured segment was 
not technically possible. Accordingly, a short 
segment of saphenous vein was prepared from 
the contralateral lower extremity. A two-inch 
segment of popliteal artery was resected. The 
reversed saphenous vein was interposed between 
the two sections of normal popliteal artery. Both 
anastomoses were performed with #4-0 Ethilon. 
Distal embolectomy with Fogarty embolectomy 
catheters was performed and followed by flush- 
ing with Heparin/ Saline solution. Excellent 
distal popliteal, dorsalis pedis, and posterior 


tibial pulses were noted immediately after the 
arterial circulation had been restored. Multiple 
fasciotomies were performed in the calf region. 

External Skeletal Fixation 

When the vascular repair was completed, an 
external skeletal fixation was employed to main- 
tain reduction of the dislocated knee, with the 
knee flexed approximately 20 to 30 degrees. 
This was then reinforced with a padded cylinder 
cast. 

Postoperatively, the patient exhibited swelling 
of the right lower extremity, particularly in the 
foot and calf regions; however, the peripheral 
pulse remained excellent, and the foot remained 
warm and pink. There was some impairment of 
dorsiflexion. indicating injury to the peroneal 
nerve. Non-weight-bearing crutch walking was 
instituted one week after surgery. Twelve days 
after surgery, the patient was transferred by 
plane out of state to convalesce with her family 
in her hometown. 

Case Two 

A 16-year-old white male struck his right knee 
against a stationary object at high speed while 
skiing. On admission to the hospital, he was 
noted to have a massively swollen, cold, and 
cyanotic right lower extremity from the mid- 
thigh downward. No popliteal, dorsalis pedis, 
or posterior tibial pulses were detectable by 
palpation or doppler. Complete instability of 
the knee joint was noted. The patient had no 
motor function of the right foot, and was 
anesthetic from the mid-ankle downward. 

The patient was taken quickly to the operating 
room and placed in the supine position, with the 
hip abducted and the knee joint maintained in 
20 to 30 degrees flexion. The popliteal space 
w r as explored through the medial approach. 
When the popliteal space was opened, a great 
deal of bleeding was noted. Complete disruption 
of both the popliteal artery and popliteal vein 
was discovered. 

Vascular control proximally and distally was 
obtained using Rummel tourniquets. A suitable 
length of saphenous vein was removed from the 
contralateral leg: and. after the damaged seg- 
ments of popliteal artery and vein were resected, 
a saphenous vein interposition was used to re- 
establish flow to the right lower extremity. 


January, 1983, Vol. 79, No. 1 


5 


Reconstructions Flushed 

Local Heparin/Saline injection was used to 
flush both arterial and venous reconstructions. 
Both were performed using #5-0 Ethilon. Both 
were end-to-end everting anastomoses. Just prior 
to the completion of the arterial anastomosis, 
the embolectomy catheter was passed through 
the distal arterial tree to remove debris and 
clots in this region. Once the anastomoses were 
completed, excellent distal popliteal, dorsalis 
pedis, and posterior tibial pulses were noted— 
both by palpation and by doppler. 

These excellent pulses remained so throughout 
the patient’s postoperative course. The extremity 
promptly became warm and pink. The popliteal 
region exhibited extensive soft tissue damage, 
with the posterior knee capsule being completely 
disrupted. Associated tendons and ligaments 
were markedly deformed and swollen. No 
obvious identifiable peripheral nerve tissue was 
observed at this time. The posterior fascial 
compartment was widely open because of the 
massive injury. 

An anterior compartment fasciotomy was then 
performed because of severe swelling in this 
region. At this point, the knee joint was stablized 
with the application of an external fixation de- 
vice. This device was tailored for the needs of 
local wound care and produced satisfactory 
stability, but this was less than optimal because 
of the needs of wound care. Because of massive 
swelling, no cast was applied. 

Skin Sutures Removed 

Twenty-four hours after surgery, the swelling 
was noted to be so marked that it necessitated 
removal of skin sutures from the medial and 
lateral incisions; however, the vascular struc- 
tures remained covered by muscle. The lower 
extremity remained anesthetic from the right 



ankle on downward. Frequent local wound care 
was performed using a sterile technique with the 
application of Betadine-soaked dressings over the 
medial and lateral incisions. 

By the fifth postoperative day, the patient was 
considered sufficiently stable to be transferred 
by air ambulance out of state to a medical center 
close to his residence for the remainder of his 
care. 

Discussion 

Mechanism of Injury : 

The mechanism of injury for most civilian 
blunt traumatic vascular injuries to the popliteal 
region involves physical contact between a mov- 
ing object and a stationary patient. In the case 
of the skier, the roles are reversed as he is the 
moving object who usually strikes a sationary 
structure, producing sudden hyperextension of 
the knee (Figure 1) with such force as to pro- 
duce a range of vascular damage varying from 
arterial intimal disruption all the way to com- 
plete transsection of the popliteal artery and 
vein. There is a range of associated injuries 
from partial to complete disruption of the knee 
joint, with or without fracture dislocation of the 
femur, tihia, and fibula. Peripheral nerve injury 
also is frequentlv associated. 

Clinical Findings: 

In both cases, the clinical examination dis- 
closed obvious evidence of vascular injury: 
absent pulses, cool temperature, severe pain, 
pallor, absence of capillary filling, and signifi- 
cant swelling and deformity at the level of the 
knee joint. Many authors 1,2,3 stress the urgency 
of prompt resuscitation and rapid transport from 
the site of injury to the operating room where 
restoration of circulation to an ischemic ex- 
tremity can begin expeditiously. 

The first case was in the operating room eight 
hours after injury, and the second case, five 
hours after injury. The delay encountered in 
these two cases was related to the geographic 
remoteness of the area where the injury occurred 
and the time necessary to arrange transportation 
to the hospital. Preoperative arteriography was 
performed in the first case, and documented the 
level of arterial obstruction. In the second case, 
it was felt that the injury was so obvious as to 
the level of vascular damage that arteriography 
would simply delay ultimate restoration of flow 
to a profoundly ischemic leg. 

Operative Management: 

Two surgical approaches have been described 
extensively. 1,3 The posterior approach, usually 


6 


The West Virginia Medical Journal 


with the patient in the prone position, was used 
successfully in the first case. In the second case, 
the medial approach proved advantageous with 
the patient in the supine position and the hip 
abducted. The medical approach is preferred 
when there are concomitant thoracic and 
abdominal injuries requiring urgent care. In 
both cases, segmental resection of the damaged 
vessel was necessary. In the first case, this was 
the popliteal artery I Figure 2). In the second 
case, this was both the popliteal artery and vein 
i Figure 3). 

In both cases, primary end-to-end anastomosis 
of the damaged vessel was not possible because 
of the length of traumatized vessel. An appro- 
priate length of autogenous vein graft was re- 
moved from the contralateral extremity and used 
successfully in each case. In the second case, 
autogenous saphenous vein graft was considered 
necessary as there was no deep venous conduit 
remaining; and, with the massive swelling at the 
time of surgery, it was doubtful that a simple 
arterial repair in the absence of a venous repair 
w r ould remain patent. A failure here would re- 
sult in inevitable limb loss and amputation. 4 In 
this case, the use of the contralateral saphenous 
vein was dictated by the need to maintain the 



ipsilateral saphenous vein as a critically neces- 
sary source of venous return. 

Systemic heparinization was not used in either 
case, and was contraindicated in the second 
case because of massive adjacent musculoskeletal 
injury. Frequent local Heparin flushes to the 
distal arterial tree and distal catheter embolec- 
tomy were performed prior to the completion of 
the arterial anastomosis in each case. Distal 
fasciotomies were required in both cases be- 
cause of massive swelling and long interval of 
ischemia to the extremities. Skeletal fixation by 
external means was used in both instances and 
was considered essential to the ultimate success 
of the vascular repair, as well as extremity 
stabilization. 

Results 

The major goal was limb salvage, and this was 
indeed successful in both cases; however, signifi- 
cant morbidity remained, particularly in the 
second case. Limb swelling resolved slowly in 
each case. Musculoskeletal problems related to 
the knee joint instability remained in each case 
and will require additional corrective surgery. 
Neurologic deficits also were a problem. In the 
first case, peroneal palsy was present. In the 
second case, there was no motor or sensory 




PROXIMAL 

POPLITEAL 

ARTERY 


PROXIMAL 

POPLITEAL 

VEIN 



SAPHENOUS 

VEIN 

SEGMENT 


SAPHENOUS 

VEIN 

SEGMENT 






DISTAL 

POPLITEAL 

ARTERY 


DISTAL 

POPLITEAL 

VEIN 


Figure 3. 


January, 1983, Vol. 79, No. 1 


7 


function from the ankle on downward. This case 
may require peripheral nerve grafting in the 
future. At the present time, this patient is 
ambulatory with the aid of a brace. 

One-Year Followup 

At one year after surgery, both patients have 
undergone successful orthopedic reconstructions 
of the affected knee joint to improve stability 
and range of motion. Both patients continue 
to have good peripheral pulses, and are ambu- 
latory, but require bracing of the affected ex- 


tremity because of the persistence of neurologic 
deficits. 

References 

1. Snyder III WH, Watkins WL et ah: Civilian pop- 
liteal artery traumas An eleven-year experience with 
eighty-three injuries. Surgery 1979; 85:101-8. 

2. Daugherty EM, Sachatello CR et ah: Improved 
treatment of popliteal artery injuries. Arch Surg 1978; 
113:1317-21. 

3. Abernathy C, Dickinson TC et ah: Management 
of popliteal artery injuries. Surg Clin 1979; 59:507-18. 

4. Rich NM, Collins GJ et ah: The effect of acute 

popliteal venous interruption. Ann Surg 1976; 183:365- 
8 . 


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Where reference is made to generically-designated drugs, the first such 
reference must be followed by parentheses containing the most commonly 
known trade-name drug of that designation. In addition, a listing of all generic 
drugs mentioned in the article, with their trade-name equivalents, should 
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A short abstract summarizing the manuscript should be included. This 
should be typed in double space on a separate page. 

Authors are requested to submit a carbon copy with the original. 

Illustrations should be numbered and their approximate locations shown 
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tended for reproduction should be done in black (India) ink on pure white. 
Photographs should be on glossy paper and minimum of about 5 by 7 in. 
in size. Cost of printing black and white photos in excess of 4 will be billed to 
author, and no more than 25 references will be published free of charge 
to the author. A legend should be provided for each illustration and, preferably, 
attached to it. 

All scientific material appearing in The Journal is reviewed by the 
Editorial Board. Manuscripts should be mailed to The Editor, West Virginia 
Medical Journal, Box 1031, Charleston, W. Va. 25324. 


8 


The West Virginia Medical Journal 



Special Article 


Emergency Maternal Transfer: An Ounce of Prevention 
For West Virginia Newborns 


ROSALIND PARKINSON, M.A. 

Department of Community Medicine, West Virginia 
University School of Medicine, Morgantown 

ROBERT C. NERHOOD, M. D. 

Department of Obstetrics and Gynecology, Marshall 
University School of Medicine, Huntington, West Vir- 
ginia 


Maternal transfer has occurred at an increas- 
ing rate in West Virginia since 1978. As a re- 
sult, a higher proportion of the state’s small pre- 
matures are note born in perinatal centers. These 
infants have experienced lower mortality rates 
than those born in other hospitals. 

* | 'he late 1970s has been a time of accelerated 
improvement in West Virginia’s infant mor- 
tality rate (Figure). Much of the increased 
infant survival is associated with collaborative 
efforts to regionalize perinatal intensive care on 
a statewide basis. 

Beginning with transfer of sick newborns to 
three tertiary centers in 1975, the perinatal pro- 
gram progressed in 1978 to organized transfer 
of mothers before delivery if there were indica- 
tions of impending problems for unborn in- 
fants.* Maternal transfers increased from 104 
patients in 1978 to 213 patients in 1980 when 
they comprised 28 per cent of all perinatal re- 
ferrals (Table 1). 

Vital statistics suggest that maternal referral 
in West Virginia conforms to the pattern re- 
ported for other states where studies indicate 
that most transfers result from signs of prema- 
ture labor. 1 While there has been little change 
in the number of small prematures born in West 
Virginia, the proportion of these infants born in 
perinatal centers nearly doubled since maternal 
transfer has become a viable option (Table 2). 

Problems in Procedure 

Maternal transfer to improve pregnancy out- 
come is recommended by organized medicine 

°The West Virginia perinatal program is sponsored by 
the West Virginia Department of Health in cooperation 
with three informally designated perinatal centers in- 
cluding Charleston Area Medical Center, West Virginia 
University Medical Center and Cabell-Huntington Hos- 
pital. 


and government agencies alike. 2,3 However, 
while it has been demonstrated that there is im- 
proved neonatal survival through maternal trans- 
fer, problems relating to the procedure spark 
considerable controversy. 4,5 Women object to 
transfer from a supportive community environ- 
ment to an unfamiliar perinatal center. The 
determination of the need for and the timing of 
maternal transfer is difficult for physicians. 
Transfer during early stages of premature labor 
is often delayed in the hope that labor can be 
stopped; when premature labor is well advanced, 
there is a hesitancy to initiate maternal trans- 
fer for fear of a precipitous delivery en route to 
the perinatal center. Sometimes there have 
been experiences of transfers where neither ma- 
ternal nor infant transfer was in fact necessary. 



Figure. Infant deaths/1,000 live births. United 
States and West Virginia, 1946-1980. 

Sources : 

1) Vital Statistics of the U.S., 1946-1978. 

2) Monthly Vital Statistics Report, Annual Summary for 
1979, DHHS Pub #(PHS) 81-1120. 

3) Health Statistics Center, West Virginia Department 
of Health, Vital Statistics 1965-1979. 

4) 1980 Provisional Data NCHS and West Virginia 
Health Statistics Center. 


January, 1983, Vol. 79, No. 1 


9 


TABLE 1 

Perinatal Transfers to Charleston Area Medical 
Center, West Virginia University Hospital and 
Cabell-Huntington Hospital, 1974-1980 



Total 

Perinatal 

# % 

Before or 

After Birth 

Year 

Antenatal 
# % 

Neonatal 
# % 

1974 

43 

100 

NA° 

0 

43 100 

1975 

109 

100 

NA 

0 

109 100 

1976 

268 

100 

NA 

0 

268 100 

1977 

428 

100 

13 

3 

415 97 

1978 

556 

100 

104 

19 

452 81 

1979 

651 

100 

185 

28 

466 71 

1980 

763 

100 

213 

28 

550 71 

“Not available 





TABLE 2 

Number and Per Cent of West Virginia Resident 
Infants Weighing Less than 2,000 Grams Born in 
West Virginia Perinatal Centers, 1974-1979 




Infants less than 2,000 grams 
Born in Perinatal Centers 

Year 



Number 


Per cent of 
State Total 

1974 



144 


23 

1975 



143 


23 

1976 



168 


29 

1977 



220 


34 

1978 



245 


37 

1979 



292 


45 


TABLE 3 

Births and Neonatal Deaths Among 
Less>-than-2,000-Gram Infants by Hospitals 
Where Births Occurred, 1977-1979 


Infants less than 2,000 grams 


Hospitals 

Live 

Births 

Neonatal Deaths/ 1,000 
Deaths Live Births 

Community Hospitals 

1192 

323 

271.0 

Perinatal Centers 

757 

146 

192.9 

Totals 

1949 

469 

240.6 


These drawbacks to maternal transfer are 
balanced by an awareness that, when born in a 
community hospital, critically ill neonates re- 
quiring immediate and prolonged supportive 
care must await transfer to a perinatal center. 
Even though labor and delivery room personnel 
may have been trained in various technical pro- 
cedures, e.g., infant resuscitation, infrequent ex- 
posure to neonatal stress may result in less than 
optimal performance in an emergency. In con- 
trast, personnel in perinatal centers manage 
problems of compromising illness in newborns 
on a virtually daily basis. 

Survival Rate Better 

West Virginia’s infant mortality statistics 
show that premature infants are more likely to 
survive when they are born in perinatal centers. 
The mortality rate among small prematures born 
in community hospitals was 40 per cent higher 
than among those born in perinatal centers in 
1977-79 (Table 3). The difference in these 
weight-specific mortality rates suggests that the 
medical environment of an infant’s birthplace 
can play an important role in determining life 
or death. For this reason, it is to be hoped that 
maternal transfer will continue and perhaps 
occur even more often in the coming years. 

References 

1. Giles HG, Isaman J, Moore WJ, Christian CD: 

The Arizona high-risk maternal transport system: An 

initial view. Am J Obstet Gynecol 1977; 128: 400-407. 

2. Committee on Perinatal Health: Toward Improv- 
ing the Outcome of Pregnancy, Recommendations for the 
Regional Development of Maternal and Perinatal Health 
Services, the National Foundation March of Dimes, New 
York, 1977. 

3. Guidelines for the Improved Pregnancy Outcome 
Program permitted federal support for emergency ma- 
ternal transfer only. No other patient care expenses were 
allowable under the program. 

4. Harris TR, Isaman J, Giles HR: Improved neo- 

natal survival through maternal transport. Obstet Gynecol 
1978; 52 (3): 294-300. 

5. Auld PAM: Maternal transport is not the answer. 
Perinatology-Neonatalogy 1978; 2(2) :8. 


10 


The West Virginia Medical Journal 


A Continuing Medical Education Event! 


The 16 th Mid-Winter Clinical 
Conference 

Charleston Marriott Hotel 

309 Lee Street, East, Charleston, WV 

January 21-23 

West Virginia State Medical Association 
West Virginia University School of Medicine 
Marshall University School of Medicine 

WATCH THE JOURNAL FOR PROGRAM DETAILS 


THE PROGRAM CHAIRMAN is Joseph T. Skaggs, M. D., of Charleston. Other members of the Pro- 
gram Committee are William O. McMillan, Jr., M. D., and C. Carl Tully, M. D., both of Charleston; 
Maurice A. Mufson, M. D., Huntington; Robert L. Smith, M. D., Morgantown, and Richard C. Starr, 
M. D., Beckley. 

THE REGISTRATION FEE of $50 for the entire conference will be charged all registrants except 
nurses, medical students, interns and residents. Advance registration is requested, and please make checks 
payable to “WEST VIRGINIA STATE MEDICAL ASSOCIATION.” 

ACCREDITATION: Attendance will be acceptable for 14 hours of Category 1 credit toward the 
Physician’s Recognition Award of the American Medical Association; and the program also is acceptable 
for 13 Prescribed hours by the American Academy of Family Physicians. 

OVERNIGHT ACCOMMODATIONS: Physicians should communicate directly with the reservation 
manager of the hotel or motor inn of their choice. The Charleston Marriott was holding a block of rooms 
for conference attendees through January 3, but reservations after that date may be requested on a space- 
available basis. In order to obtain group rates, those who make reservations directly with the head- 
quarters hotel should specify that they will be attending the Mid-Winter Clinical Conference. Group rates 
are $48 for a single room and $54 for a double. Those who register in advance for the Conference with 
the State Medical Association (see below) will receive from the Association a postage-paid Marriott reser- 
vation request card specifically designated for Mid-Winter Clinical Conference registrants. 

FOR ADVANCE REGISTRATION, please complete the form below and mail to: WEST VIR- 
GINIA STATE MEDICAL ASSOCIATION, P. O. BOX 1031, CHARLESTON, W. VA. 25324. 


Please register me for the 16th Mid-Winter Clinical Conference in Charleston, WV, January 21-23. 
My $50 registration fee is (is not) enclosed. 


Name (please print ) 


Specialty 


Address 


City 


January, 1983, Vol. 79, No. 1 


11 


*Jhe PzeAident 



<7% meAAage from . . . 


HIGH COST OF DEFENSIVE MEDICINE 


/ T"*HIS month, I would like again to address the 
A broad issue of cost of health care. This topic 
has been very prominent in the news recently. 
It is obviously one of the prime concerns of the 
national administration and our state govern- 
ment, as well as private citizens and the medical 
profession. 

We understand from statistics compiled by the 
U. S. Department of Health and Human Services 
that total health care expenditures, public and 
private, rose 15.1 per cent from 1980 to 1981. 
We also note, although this is not emphasized, 
that health care expenditures have been rising 
steadily since Congress created Medicare and 
Medicaid in 1965 and, a figure noted but not 
emphasized, the average increase from 1976 to 
1981 was 13.9 per cent. I am at a loss to see 
how politicians this year panic over the differ- 
ential increase of 1.2 per cent from the average 
1976 to 1981 figures, especially as HHS states 
price inflation was responsible for 70 per cent of 
the increase, and aging of the population for 20 
per cent of the increase. Perhaps the reason is 
that approximately 42.8 per cent of total health 
care cost was spent by Federal, state and local 
governments, according to their figures. Perhaps 
their concerns stem from the realization that the 
promises they made regarding health care in the 
past decade are coming home to haunt them, and 
the bill is far higher than they had anticipated. 

Be that as it may, I would like to address an- 
other aspect of the cost of medicine which has 
not been looked at by the politicians, bureaucrats 
and regulators in their attempt to control the ris- 
ing cost of health care. This is the field of de- 
fensive medicine — the tests that are done not for 
good clinical reasons but in order to protect the 
practitioner from legal action and t,o insure that 
if legal action is commenced he will be found to 
have done as much or more than one could or 
should do. 

The rationale for ordering these defensive tests 
and procedures may be indefensible clinically. 


but it certainly is defensible from a practical, 
legalistic point of view. One has only to look at 
the ever-increasing amounts of money awarded to 
plaintiffs (and incidentally, plaintiffs’ lawyers) 
for relatively minor problems. Examples, such as 
$800,000 for a misplaced navel or $150,000 be- 
cause of a scar at an IV site, abound; therefore, 
the reason for ordering ETKTM (Every Test 
Known To Man ) to CYA ( Cover Your A- ) is ap- 
parent. 

I read with interest in the media that physi- 
cians' fees rose approximately 9.8 per cent this 
year while inflation is predicted to be 5-6 per 
cent and, therefore, our fees are considered to be 
excessive. Nowhere, however, do I read certain 
other figures. For example, medical malpractice 
insurance will average increases in the range of 
25 per cent in our state for next year, and utility 
fees, prices of supplies, and of our phone service 
show no signs of decreasing, regardless of the 
decrease in tffe CPI. 

This leads me to believe that a good place to 
halt the rate of increase in medical care would 
be to have some attention from the politicians, 
bureaucrats, regulators and media to provide tort 
reform to help decrease at least one parameter of 
the ever-increasing spiral of costs. After all, 
physicians’ costs, like any other professionals’, 
are passed along to our patients, for we have no 
other sources of revenue. EUtimately, if govern- 
ment at all levels pays 42.8 per cent of the bill, 
the cost of these exhorbitant awards is borne by 
every taxpayer, and this is the fact that needs to 
be brought to his or her attention. 






Harry Shannon, M. D., President 
West Virginia State Medical Association 


12 


The West Virginia Medical Journal 


The Vest Virginia fledical Journal 

Editorials 

The Publication Committee is not responsible for the authenticity of opinion or statements made by authors or 
in communications submitted to this Journal for publication. The author shall be held entirely responsible. 
Editorials printed in The Journal do not necessarily reflect the official position of the West Virginia State 
Medical Association. 


In the news section of The Journal is a story 
outlining proposed State Medical Association 
positions, and efforts to seek passage of several 
measures, in the upcoming legislative session to 
begin January 12. 

The Association again will be in a posture 
established and maintained effectively over the 
past several years — one of offering 
GENERAL ideas of its own with respect to pro- 
QUARTERS moting the general health and wel- 
fare. It proposes to be aggressive in 
espousing those views — and that's where the 
general membership must play a role. 

Bills related to health and medical care have 
mushroomed in lawmiaking bodies across the 
nation in the last decade or so, beginning with 
far-reaching measures introduced into, and fre- 
quently enacted by, the Congress. 

Some of that legislation is not consistent with 
such things as cost effectiveness in the true sense 
of the word — a proper blending of reasonable 
efforts to blunt costs but at the same time pro- 
tecting the availability of, and access to, quality 
care. 

That general problem certainly will be a major 
one with which physicians and others must deal, 
and play an active role in. during the upcoming 
session. As always at this time of year, doctors 
are urged to stay abreast of legislative develop- 
ments, and in contact with their legislators. The 
doctors in practice are the constituency of those 
senators and delegates, not the State Medical 
Association headquarters. 

Every effort will be made, through legislative 
bulletins and other means, to keep the Associa- 
tion membership informed on as current a basis 
as possible. But we plead with you to heed those 
communications, and immediately speak out if 
you see any problems or have questions. 

In other words, were again going to "general 
quarters,’' heading into mid-January. This alert 


needs to be constantly in your minds — and you 
need to be ready as your help might be needed. 


Anywhere a physician might care to look 
these days, he or she can find a new study or 
survey related to medical or health care. Some 
of the results might appear positive, 
SURVEYS others just the opposite — all of which 
underlines the crazy times in which 

we live. 

Many of the surveys have been by American 
Medical Association components, and one re- 
cently determined that the public had strong 
pro-physician attitudes on professional liability 
issues. Most people didn't think malpractice 
suits usually were justified, although 47 per cent 
held the opposite view. 

The majority I 61 per cent ) of the respon- 
dents in 1.504 telephone interviews favored 
limits on malpractice awards (something that 
generally has not been looked upon w r ith favor 
by the courts across the land I . Forty-seven per 
cent of the public respondents thought current 
awards have run too high, with seven per cent 
saying not high enough. 

Ninety-two per cent of the 1,000 physician 
respondents in the AMA survey rated better 
physician-patient rapport as a very effective 
method for reducing professional liability risk. 
No other proposals for reducing risks — such as 
more peer review, continuing medical education 
and risk management seminars — got more than 
a 38-per cent approval rate. 

On average, physicians surveyed estimated 
that 22 per cent of malpractice claims result 
from actual negligence. Most physicians ( 62 
per cent ) said hospital staffs should require evi- 
dence of professional liability insurance for staff 
privileges. 

Then there was another recent AMA survey 
of physicians showing a growing concern over 


January, 1983, Vol. 79, No. 1 


13 



competition in medicine. An increasing number 
of physicians believed there are too many doc- 
tors in their communities: 33 per cent in 1981 
and 40 per cent in 1982. 

Fewer than half the physicians surveyed (47 
per cent) have been experiencing an increasing 
patient load in the last few years, and only about 
one-third (35 per cent) reported their incomes 
increasing. 

Thirty-nine per cent said unemployment les- 
sened their patient load; 67 per cent reported 
that unemployment had lessened the ability of 
patients to pay. A current or impending surplus 
of doctors was foreseen by 72 per cent of those 
surveyed. 

The AMA surveying group concluded that, 
taken in combination, the study’s findings in- 
dicated competition for patients was increasing 
among physicians, and was having a definite im- 
pact on medical practice in the nation. 

What about concerns regarding medical costs? 
In still another AMA study, results showed that 
such concern was growing among physicians and 
the general public alike. Physician concern over 
costs increased sharply over a one-year period, 
while concern about government regulation or 
access to medical care dropped correspondingly. 
(We’d suggest that, in the wake of recent con- 
gressional action and a flood of new Department 
of Health and Human Services regulations, feel- 
ings about regulation will do another turnabout 
in the next survey.) 

Telephone interviews with randomly selected 
physicians showed 58 per cent listing cost to be 
the main problem facing medicine today. Last 
year, the figure was 44 per cent. In 1,504 tele- 
phone interviews with public respondents also 
selected at random, 62 per cent — as compared to 
55 per cent last year — said cost was the main 
problem facing health care and medicine. 

The survey found that almost half (47 per 
cent) of the American people believed that not 
enough of society’s resources is being directed 
to health care, and only 16 per cent felt too much 
is being spent. 

But is health care the public’s highest priority 
when it comes to spending more money? No. 
Public respondents gave a higher ranking to 
education, the environment and financial assist- 
ance to the poor. 


All of these survey results will mean somewhat 
different things to different people. But one of 
the findings again sticks out like a mountain, 
and for the third time in this month’s editorials 
we must emphasize it. It’s doctor-patient rap- 
port. 


The House Staff Council at the Charleston 
Area Medical Center organized something new 
this year, at least for that institution. It was 
a multidisciplinary conference on 
MEDICAL “Medical Pearls, ’’.with some 15 medi- 
PEARLS cal specialists presenting short, clini- 
cally useful bits of information. 

The subjects ranged from nephrology to 
various aspects of surgery; from pulmonary 
medicine to obstetrics; and from platelets to 
vertigo. Perhaps other medical staffs in the state 
conduct similar conferences, although the CAMC 
presentations were set up largely for senior 
medical students and residents. If not, they 
might want to consider at least the general idea. 

Along with observations and subjects directly 
related to day-to-day practice were reviews of 
new technology and thinking. And there like- 
wise were some expressions of what commonly 
can be called good old-fashioned “horse sense.” 

One internist told the audience to always keep 
foremost in mind affability, along with ability 
and availability, in professional relationships 
with patients. 

Humor is very important in the practice of 
medicine, and if you cannot convey an image of 
humor, a smile is the next best thing, he said. 
As for one who finds friendliness beyond his 
capabilities, it must be back to the proverbial 
drawing board. 

Listen to your patients, said another physi- 
cian, because they usually will tell you what 
you need to know — even though you might have 
to listen “between the lines" to hear it. 

He emphasized that “the family can either be 
your worst enemy or your greatest friend." both 
in encouraging patient compliance and (along 
with nurses, secretaries and others ) in observing 
the patient outside the confines of the examining 
room or office. 

Old hat, you say, with respect to these kinds 
of “pearls?” Rapport is never old hat. It re- 
mains the cornerstone of the doctor-patient re- 
lationship, a fact never more apparent than in 
today’s complex life patterns. 


14 


The West Virginia Medical Journal 


GENERAL NEWS 


Sports Medicine Specialist, 
Attorney To Speak 

A University of Virginia physician who has 
received numerous awards in the field of sports 
medicine will be a member of the faculty for the 
16th Mid-Winter Clinical Conference, the Pro- 
gram Committee announced. 

The annual continuing education program 
will begin at 2 P. M. on Friday, January 21, 

at the Marriott Hotel 
in Charleston, and end 
at noon on Sunday. 
The faculty will con- 
sist of 13 principal 
speakers for sessions 
Friday afternoon and 
evening, Saturday 
morning and after- 
noon, and Sunday 
morning. 

Sponsors are the 
State Medical Associa- 
tion and the Marshall 
University and West 
Virginia University School of Medicine. 

“We believe we have an outstanding faculty, 
and we have tried to provide many of the sub- 
jects requested by doctors.'’ said Joseph T. 
Skaggs, M. D., Charleston. Chairman of the 
Program Committee. 

Dr. Frank C. McCue III. a native of Max- 
welton. Greenbrier County, and a member of the 
medical staff at the University of Virginia in 
Charlottesville, will speak on “Sports Medicine 
for the Family Physician" during the Saturday 
morning session. He is Director, Hand Surgery 
and Sports Medicine Division, Department of 
Orthopedics and Rehabilitation, at the Uni- 
versity, and also is Team Physician for the 
Athletic Department. 

Among a number of sports medicine awards 
received by Doctor McCue are the National 
Distinguished Service Award from the National 
High School Coaches Association in appreciation 
for interest in the care of high school athletes 
(1977); Certificate of Appreciation from the 
Medical Society of Virginia for recognition of 



Gary A. Banas, L.L.B. 


contributions to Sports Medicine in Virginia 

I 1979); and the National Athletic Trainers As- 
sociation President’s Challenge Award for 1980. 

Also Public Session Speaker 

Doctor McCue also will be the speaker for 
the public session Friday evening. “Medical 
Care for the Athlete — What You Should Know” 
will be the title of his talk. 

As announced previously, a physicians’ ses- 
sion on “The Doctor, Quality Control and Pro- 
fessional Liability” will be held concurrently 
with the public session Friday evening. Gary 
A. Banas, an Akron. Ohio, attorney, will be the 
principal speaker. Doctor Skaggs, w'ho is 
Director of Medical Affairs at Charleston Area 
Medical Center (CAMC), will preside. 

Panelists will be Tom Auman, Director of 
Professional Liability, McDonough Caperton 
Shepherd Group. Charleston; Fred Bockstahler, 
J.D., Director of Patient Affairs, CAMC; James 
C. Crews, CAMC President; Jack Leckie, M. D., 
Huntington, Chairman of the Committee on In- 
surance, West Virginia State Medical Associa- 
tion, and John F. Wood, J.D.. Huntington at- 
torney. 

Lt. Colonel Fred Donohoe, Chief of the West 
\ irginia State Police, the Program Committee 
also announced, will make brief remarks during 
the Saturday morning session. Colonel Donohoe 
will talk about efforts to secure state funds in 
1983 to expand and continue the pilot State 
Police MEDEVAC air medical rescue program 
which otherwise expires this month. (See story 
elsewhere in this issue of The Journal.) 

‘Meet the Faculty’ 

Other features of the conference will be 5 
o’clock “Meet the Faculty” cash bars following 
the afternoon session on Friday and Saturday, 

I I scientific exhibits, and meetings of other 
medical groups as listed in the program. 

Doctor McCue is a Diplomate of the American 
Board of Orthopedic Surgery, and a Fellow of 
the American Society of Surgery of the Hand, 
American Academy of Orthopedic Surgery, 
American College of Surgeons, and American 
Society of Sports Medicine. He was a founding 


January, 1983, Vol. 79, No. 1 


15 


member of the American Orthopedic Society for 
Sports Medicine. 

Doctor McCue received his undergraduate and 
M. D. ( 1956 ) degrees from the University of 
Virginia. He interned at the Kansas University 
Medical Center, took a residency in orthopedic 
surgery at the University of Virginia, and 
studied surgery of the hand for two years under 
physicians in Los Angeles. 

He is the author or co-author of some 70 
scientific articles, and chapters in six books. 

Other Speakers 

The other previously-announced speakers and 
topics are: 

Friday Afternoon : “Diagnostic Tests in 

Hepatitis” — Robert H. Waldman, M. D., WVU 
Professor of Medicine and Acting Dean, School 
of Medicine, Morgantown; “Vaccines in the 
Treatment of Hepatitis” — Larry I. Lutwick, As- 
sociate Professor of Medicine, State University 
of New York, Downstate Medical School: and 
Associate Director, Department of Medicine, 
and Director, Division of Infectious Diseases. 
Maimonides Medical Center, Brooklyn; and 
“Herpes” — Jack M. Bernstein, M. D., ML! As- 
sistant Professor of Medicine; 

Saturday Morning: “Trauma Transport” — 

James W. Kessel, M. D., Charleston surgeon; 
and “Joint Replacement" — J. David Blaha, 
M. D., WVU Assistant Professor, Department 
of Orthopedic Surgery; and Chief, Section of 
Arthritis Surgery, Morgantown; 

Saturday Afternoon: “New Developments in 
Prenatal Diagnosis” — R. Stephen S. Amato, 
M. D., Ph.D., WVU Professor of Pediatrics and 
Medical Director, Affiliated Facility for De- 
velopmentally Disabled, Morgantown: “Heritable 
Immunodeficiency Disease — New Prospec- 
tives” — Martin R. Klemperer, M. D., MU Pro- 
fessor and Chairman, Department of Pediatrics; 
and “Nephrotic Syndrome in Children” — 
Roberta Gray, M. D., MU Associate Professor of 
Pediatrics; 

Lens Replacement 

Sunday Morning: “Lens Replacement” 

George W. Weinstein, M. D., WVU Professor 
and Chairman, Department of Ophthalmology, 
Morgantown; “Use and Abuse of Tricyclic Anti- 
depressants” — William H. Nelson, M. D., As- 
sociate Professor of Psychiatry, University of 
Connecticut, Farmington; and Chief, Ambulatory 
and Consultation Psychiatry, Veterans Admini- 
stration Medical Center, Newington, Connecticut; 
and “Calcium Channel Blockers” — Robert C. 


Touchon, M. D., MU Associate Professor of 
Medicine and Chief of Cardiology, Department 
of Medicine. 

Presiding physicians in addition to Doctor 
Skaggs will be Maurice A. Mufson, MU Profes- 
sor and Chairman, Department of Medicine 
(Friday Afternoon); Tony C. Majestro, Charles- 
ton. WVU Clinical Associate Professor, Depart- 
ment of Orthopedic Surgery (Friday Evening 
Public Session ) ; Thomas F. Scott, Huntington, 
MU Clinical Associate Professor of Surgery 
(Saturday Morning); Herbert H. Pomerance, 
Chairman, Department of Pediatrics, CAMC, 
and Professor and Director of Pediatrics, WVU 
Charleston Division (Saturday Afternoon); and 
John W. Traubert, WVU Professor and Chair- 
man. Department of Family Practice, Morgan- 
town ( Sunday Morning ) . 

Other Meetings 

Other meetings scheduled at the Marriott in 
conjunction with the conference include the 
Family Medicine Foundation of West Virginia, 
Thursday evening, January 20; Board of Di- 
rectors, West Virginia Chapter, American 
Academy of Family Physicians, Friday evening; 
West Virginia State Society of Anesthesiologists, 
Saturday noon; WESPAC dinner, Saturday even- 
ing, and the State Medical Association's Cancer 
Committee, Sunday morning. 

Speakers for the WESPAC dinner will be 
Peter B. Lauer. Executive Director and Treasurer 
of AMPAC ( American Medical Political Action 


Conference Exhibits 

Physicians and others attending the 16th 
Mid-Winter Clinical Conference will have the 
opportunity to see some 11 scientific exhibits. 
Exhibitors scheduled to date include: 

West Virginia Department of Health; 
American Heart Association, West Virginia 
Affiliate; Family Medicine Foundation of 
West Virginia; McDonough Caperton Shep- 
herd Association Group: Nationwide Insur- 
ance — Medicare; American Cancer Society, 
West Virginia Division, Inc., Kanawha 
County Unit; Kanawha County Chapter, 
Physicians for Social Responsibility; Allergy 
Rehabilitation Foundation, Inc.; West Vir- 
ginia Lung Association, Inc.; J. B. Lippincott, 
Division of Harper and Row, Pittsburgh; and 
Medical Publisher’s Representative, Inc., 
Cincinnati. 


16 


The West Virginia Medical Journal 


Committee ) and W. Leonard Weyl, M. D., of 
Arlington. Virginia, AMPAC Board member. 

The program meets the criteria for 14 hours 
of credit in Category 1 of the Physician’s 
Recognition Award of the American Medical 
Association, and is approved for 13 Prescribed 
hours by the American Academy of Family 
Physicians. 

A registration fee of $50 will be charged all 
registrants except nurses, medical students, in- 
terns and residents. For advance registration, 
make checks payable to West Virginia State 
Medical Association, and mail to the Association 
at P. 0. Box 1031, Charleston 25324. 

Hotel Reservations 

The Charleston Marriott was holding a block 
of rooms for conference attendees through 
January 3, but reservations after that date may 
be requested on a space-available basis. Those 
making reservations — in order to receive group 
rates — should specify that they will be attending 
the Mid-Winter Clinical Conference. Group 
rates are $48 for a single room and $54 for a 
double. 

Other members of the Program Committee 
are Drs. William 0. McMillan. Jr., and C. Carl 
Tully, both of Charleston; Richard G. Starr, 
Beekley: Maurice A. Mufson. Huntington, and 
Robert L. Smith, Morgantown. 

The Program Committee is receiving continu- 
ing assistance from WVU Charleston Division 
staff members J. Zeb Wright, Ph.D., Coordinator 
of Continuing Education. Department of Com- 
munity Medicine; and Sharon A. Hall, Con- 
ference Coordinator. 


Joint Appointment For MU, 
Hospital Announced 

The first joint faculty appointment for the 
Marshall University School of Medicine and 
Huntington State Hospital has been announced 
by the two institutions. 

Dr. Eric H. Sawitz, Assistant Professor of 
Familv and Community Health, will spend 40 
per cent of his time at the State Hospital, where 
he will be responsible for three wards of develop- 
mental^ disabled persons. He will work with 
hospital staff to develop and expand services for 
the patients. 

“We all are interested in developing a relation- 
ship between Huntington State and Marshall 


which would improve patient care,” Doctor 
Sawitz said. 

Doctor Sawitz previously served as Medical 
Director and internist at the Cabin Creek 
Medical Center in Dawes, and received bis M. D. 
in 1976 from Boston University. He has served 
as a consultant in internal medicine for the West 
Virginia Division of Vocational Rehabilitation, 
and medical consultant and a member of the 
board of the Kanawha County Special Olympics. 


Huntington Burn Unit 
Taking Referrals 

A burn intensive care unit at Cabell-Hunting- 
ton Hospital in Huntington is now in operation. 
Designated for the specialized treatment of 
patients from West Virginia, eastern Kentucky 
and southwestern Ohio, the burn unit opened 
formally in November. 

The four-bed unit is housed adjacent to the 
general intensive care unit in the critical care 
wing. The phvsicial therapy (hydrotherapy) 
room is in the unit, and isolation techniques 
keep it apart from normal traffic patterns. 

The planning and design of the unit began 
in 1977 when the administrators of the hospital 
took a bard look at its critical care units and 
decided that, in addition to new facility con- 
struction, it would provide a new service as well, 
that of specialty care of the burn victim. 

A group of surgeons, Marshall University 
surgical residents, burn nurses, physical thera- 
pists, dietitians, and social workers apply the 
“burn team concept to the patient and his 
family. The unusually severe disruption of the 
family by this type of injury is appreciated by 
the team, and was a compelling reason for the 
hospital to provide an in-state service for West 
\ irginia and tri-state residents, according to Dr. 
James A. Coil. Jr., M. D., Professor of Surgery 
at Marshall L^niversity School of Medicine, who 
is Medical Director of the burn unit. 

Referrals 

Referring physicians can call the unit directly 
at 1 304 ) 696-6107 for information or patient 
transfer. In addition, a burn clinic meets for 
the evaluation of long-term reconstruction and 
rehabilitation of burn victims. 

As a guideline for emergency referral, the 
American Burn Association’s criteria for burn 
unit admission apply; 1. partial-thickness injury 


January, 1983, Vol. 79, No. 1 


17 


of more than 20 per cent body surface area; 2. 
full thickness of more than 10 per cent of body 
surface area; 3. full-thickness burns of the face, 
hands, or feet; 4. inhalation injury; 5. serious 
associated medical problems; and 6. electrical 
burns. 

The unit has the hope of being a resource 
facility for the state, and members of the hospital 
team are accepting invitations on a limited basis 
to speak on burn care. An awareness that the 
best burn treatment is prevention will be a major 
thrust of future educational effort, said Doctor 
Coil. 


Doctor Reed, Past President, 
Dies In Charleston 

Thomas G. Reed of Charleston, President of 
the State Medical Association in 1949, died 

on December 7 at his 
home. He was 84. 

A retired urologist 
and a native of Hardy 
County, Doctor Reed 
began practice in 
Charleston in 1930. 

Doctor Reed was a 
member of the As- 
sociation’s Council 
from 1945 through 
1948, and was an 
Alternate Delegate to 
the American Medical 
Association in the 

sixties. 

He was a member of the former West Virginia 
Medical Licensing Board from 1965 to 1970. 

Doctor Reed was certified by the American 
Board of Urology, a Fellow of the American 
College of Surgeons, and a member of the 
American Urological Association. He received 
his M. D. degree in 1926 from Jefferson Medical 
College in Philadelphia. 

Doctor Reed was an honorary member, and 
a Past President of, the Kanawha Medical 
Society, and an honorary member of the West 
Virginia State Medical Association and the 
American Medical Association. 

Surviving are the widow; two daughters, Mrs. 
Frederick H. Belden, Jr., of Charleston and Mrs. 
Gary C. Caylor of Houston, Texas; three sisters, 
Mrs. Beulah Heltzel of Wardensville, Mrs. Essye 
Bean of Moorefield and Mrs. Olga Walker of 
Wheaton, Maryland, and six grandchildren. 


Continuing Education 
Activities 

Here are the continuing medical education 
activities listed primarily by the West Virginia 
University School of Medicine for part of 
1983, as compiled by Dr. Robert L. Smith, 
Assistant Dean for Continuing Education, and 
J. Zeb Wright, Ph. D., Coordinator, Con- 
tinuing Education, Department of Community 
Medicine, Charleston Division. The schedule is 
presented as a convenience for physicians in plan- 
ning their continuing education program. (Other 
national, state and district medical meetings are 
listed in the Medical Meetings Department of 
The Journal. ) 

The program is tentative and subject to 
change. It should be noted that weekly confer- 
ences also are held on the Morgantown, Charles- 
ton and Wheeling campuses. Further information 
about these may be obtained from: Division of 
Continuing Education. WVU Medical Center, 
3110 MacCorkle Avenue, S. E., Charleston 
25304: Office of Continuing Medical Education. 
WVU Medical Center, Morgantown 26506; or 
Office of Continuing Medical Education. Wheel- 
ing Division, WVU School of Medicine, Ohio 
Valley Medical Center. 2000 Eoff Street. Wheel- 
ing 26003. 

Jan. 24-28, Snowshoe. Fourth Mid-Winter Car- 
diovascular Symposium 

Feb. 6-9, Snowshoe, Surgical Conference 

March 18, Charleston, 10th Annual Newborn 
Day 

March 25-26. Morgantown. Infection Control 
Workshop 

March 28-29, White Sulphur Springs, Sym- 
posium on Tumors for the Orthopedic 
Surgeon 

Regularly Scheduled Continuing 
Education Outreach Programs from 
WVU Medical Center/ 
Charleston Division 

Cabin Creek, Cabin Creek Medical Center, 
Dawes, 2nd Wednesday, 8-10 A. M. — Jan. 
12, “Recently Recognized Sexually-Trans- 
mitted Diseases.” Thomas W. Mou, M. D. 

Gassaway, Braxton Co. Memorial Hospital, 1st 
Wednesday, 7-9 P. M. — Jan. 5, “Evaluation 
& Management of Thyroid Nodules,” Richard 
Kleinmann, M. D. 



Thomas G. Reed, M. D. 


18 


The West Virginia Medical Journal 



Feb. 2, “Yes, Virginia, There Are Venereal 
Diseases in Rural Practices,” Patrick Robin- 
son, M. D. 

Welch, Stevens Clinic Hospital, 3rd Wednesday, 
12 Noon-2 P.M. — March 16, “Protocols for 
Treating Poisonous Snake Bites,” Edward 
Wright, M. D. 

Buckhannon, Madison, Oak Hill, Whitesville, 

Williamson — I winter break in January). 


Council Agenda Highlighted 
By Legislative Issues 

The Medical Association’s Council, acting on 
recommendations of the Committee on Legisla- 
tion’s steering subcommittee, has approved an 
ambitious program for the 1983 state legislative 
session to begin January 12. 

Council directed preparation of eight hills, 
mostly in the area of so-called tort reform re- 
lated to professional liability, and voted support 
of a measure to set up a simplified mechanism 
for obtaining corneas for transplant. 

It left to the judgment of the leadership and 
the Committee on Legislation positions which 
might be taken on bills in the area of hospital 
rate setting and review, and hospital board 
composition, once staff has an opportunity to 
study measures actually introduced. 

Bills Council directed prepared would: 

Prohibit inclusion of a dollar amount in a 
malpractice claim; tighten the statute of limita- 
tions under which actions are brought; modify 
the collateral source rule which now prohibits 
evidence at trial of a patient’s compensation 
from sources other than the defendant. 

Payments for Future Damages 

Mandate periodic payments for future dam- 
ages; require juries to apportion damages among 
defendants; establish a fee schedule for 
attorneys’ fees based on amounts of recovery; 
place a $250,000 maximum on recovery for pain 
and suffering, and other-economic losses; and 
provide by statute, with specific limitations, 
procedures through which patients could obtain 
copies or summaries of patient records. 

In other action at its November 21 meeting. 
Council: 

— Elected to honorary membership, after 
appropriate component society action, C. R. 
Davisson. M.D.. of Weston: J. Carlton Godlove, 
M. D.. Martinsburg, and Edward Gliserman. 
M. D., Holden in Logan County. 

— Adopted a “mission statement" reiterating 
the Medical Association’s commitment to con- 


tinuing medical education, and particularly to 
its role as an accrediting arm of the national 
Accreditation Council for Continuing Medical 
Education ( ACCME ) with respect to such 
intrastate programs as those reviewed and 
approved at community hospitals. 

— Approved for calendar and fiscal 1983 a 
Medical Association operating budget of $494,- 
505, a figure only $599 above the budget for 
1982. 

— Approved a survey of State Medical As- 
sociation members as to ( 1 ) whether they favor 
the concept of construction of an Association 
headquarters building on property now owned 
in Charleston; and (2) whether the members 
would be willing to purchase tax-exempt in- 
dustrial revenue bonds issued by West Virginia 
State Medical Association Properties, Inc., to 
finance such construction. 

— Approved expenditures of up to $4,500 a 
year from the Association’s operating funds, as 
advances toward reimbursement, to cover 
properties corporation expenses such as taxes, 
audit costs and other minor items until that 
corporation has its own financial operating plan. 

— Approved endorsement of a collection 
service offered by I.C. System, Inc., of St. Paul, 
Minnesota, with a proviso that funds accruing 



Dr. Alex Wanger of Martinsburg, center, and Dr. 
William Wanger of Beckley were among partici- 
pants at the recent 8th annual Hal Wanger Family 
Practice Conference at the West Virginia University 
Medical Center. The conference was named for 
their father, an early leader in continuing medical 
education in the state. The late Dr. Hal Wanger 
inaugurated the Potomac-Shenandoah Valley Post- 
graduate Institute, forerunner of the present con- 
ference. Chatting with the Doctors Wanger is Brita 
Nieland. 


January, 1983, Vol. 79, No. 1 


19 



to the Medical Association as a result of the 
endorsement he to the benefit of the properties 
corporation. 

- — Re-elected Joe N. Jarrett, M.D., of Oak Hill 
to a new seven-year term on the Publication 
Committee, with the term to begin January 1, 
1983. 

— Endorsed TEL-MED, a library of taped 
telephone messages on a variety of health and 
health-related topics for the general public. 


Association Committee Hears 
WVU Funding Review 

The West Virginia University Medical School, 
troubled by some 1982-83 budget reductions, 
needs an additional legislative appropriation of 
$8 to $9 million for next year just to keep pro- 
grams at 1981 levels, John E. Jones, M. D., has 
explained. 

Doctor Jones, WVU’s Vice President for 
Health Sciences, reviewed in detail the School 
of Medicine’s budget request at a recent meet- 
ing of the State Medical Association’s WVU 
Liaison Committee in Bridgeport, 

He noted that WVU has no remaining “bal- 
ance forward’’ funds in its account to carry it 
into the 1983-84 fiscal year, for which the Legis- 
lature to convene January 12 will have to 
fashion operating budgets for state departments, 
agencies and institutions. The Medical Center 
cut programs by $2.9 million in 1982-83. 

A proposed two cents-a-bottle increase in the 
state’s soft drinks tax — one source of funds for 
the medical school — could produce an additional 
$15 million a year, with half to be used for 
operational purposes and half for capital ex- 
penditures, Doctor Jones said. 

Hospital Updating Needed 

He explained that the aging West Virginia 
L T niversity Hospital will require expenditures of 
perhaps $30 million in the next few years to 
bring it in line with current fire, safety and other 
codes. 

On a continuing somber note, Doctor Jones 
said that a faculty movement projection as of 
September 22, 1982, indicated a potential loss 
this school year of 44 physicians for a variety of 
reasons, including the salary structure and other 
feelings of instability. 

Turning to the brighter side. Doctor Jones 
said WVU would be making significant new 
efforts to “tell its story better” as to the quality 
of its programs and graduates, and increased 
retention of physicians in West Virginia. The 
WVU School of Medicine was re-accredited in 


March for another four years, with an interim 
report set for 1985 a possible basis for a request 
for a further accreditation extension. 

The Liaison Committee, chaired by James L. 
Bryant. M. D., of Clarksburg, commended Doc- 
tor Jones for authorship of a special article, 
“Financing of the West Virginia University 
School of Medicine,” printed in the November. 
1982, issue of The Journal. 


‘Selected’ Providers Suggested 
By Health Task Force 

Number one on a list of nine priority recom- 
mendations by a Health Cost Containment Task 
Force calls for legislation to create a state regula- 
tory commission with authority to limit amounts 
hospitals charge patients. 

Recommendation No. 2 proposes that hospitals 
and medical services provided hy state funds be 
expended pursuant to “State procedures that pro- 
vide a more cost-effective delivery of hospital and 
medical services.” 

In elaborating on the second recommendation, 
the final report by the Task Force — set up by 
Governor Rockefeller in September. 1981 — pro- 
vides some interesting reading. It says the 


Review A Book 


The following books have been received hy the 
Headquarters Office of the State Medical Associa- 
tion. Medical readers interested in reviewing any 
of these volumes should address their requests to 
Editor. The West Virginia Medical Journal. Post 
Office Box 1031. Charleston 25324. We shall be 
happy to send the hooks to you. and you may 
keep them for your personal libraries after sub- 
mitting to The Journal a review for publication. 

Current Obstetric and Gynecologic Diagnosis 
and Treatment , 4th Edition, edited by Ralph 
C. Benson, M. D. 1,038 pages. Price $25. 
Lange Medical Publications, Los Altos. Cali- 
fornia 94022. 1982. 

Stand Tall! — The Informed IV Oman’s Guide 
to Preventing Osteoporosis, by Morris Notelovitz, 
M. D., and Marsha Ware. 208 pages. Price 
$12.95. Triad Publishing Company. Inc., P. 0. 
Box 13096. Gainesville, Florida 32604. 1982. 

Basic and Clinical Pharmacology, by Bertram 
G. Katzung, M. D.. Ph.D. 815 pages. Price 
$23.50. Lange Medical Publications, Los Altos, 
California 94022. 1982. 


20 


The West Virginia Medical Journal 



recommendation addresses the fact “that the 
State is contributing to the high cost of health 
care by permitting the free selection of hospitals 
by persons whose hospital and medical services 
are paid by the State." Here is further material 
from the report: 

“This recommendation could be implemented 
by having the State select hospitals and medical 
providers that provide the most cost-effective 
services and authorizing payment for those ser- 
vices not to exceed the State-approved rate. 

“For example, in areas of the State with two 
or more hospitals, the State could select the 
hospital providing the most cost-effective service 
and pay only the amount that hospital might 
charge, regardless of where the area residents 
might receive their services. 

“If payments to hospitals and medical pro- 
viders by the West Virginia Public Employees 
Insurance Board, the Welfare Department, the 
Workmen's Compensation Fund and all other 
State-funded health payment programs were 
made utilizing the rates of the most cost-effective 
provider (s) in the area where the patient resides, 
then a substantial saving would be made by the 
State. 

“In addition, such a program would stimulate 
competition among providers to deliver the same 
quality service at the least cost.” 

The Task Force came up with 50 recommenda- 
tions in all in the report made to the Governor 
and the Legislature shortly before December 1. 


Houston Doctor Named 
WVU Medical Dean 

Dr. Richard A. DeVaul, Associate Dean 
of the University of Texas Medical School 
at Houston, has been named Dean of the 
West Virginia University School of Medicine, 
it was learned as The Journal went to press. 

Doctor DeVaul will assume his new posi- 
tion in the spring, said Dr. John E. Jones, 
WVU V ice President for Health Sciences. 

Doctor DeVaul, 42. a native of Ames, Iowa, 
specializes in psychiatry. He received his 
M. D. degree from the Llniversity of 
Rochester, and did his psychiatric residency 
at Johns Hopkins University. 

Doctor Jones said Doctor DeVaul “is a 
man of outstanding credentials. 

Doctor DeVaul will succeed Dr. Robert H. 
Waldman. who was named Interim Dean 
after Doctor Jones was promoted to his cur- 
rent job last April. 


At this writing, what bills for legislative con- 
sideration might be generated by the recommen- 
dations was not known, but a bill or bills to 
establish a hospital rate review and rate-setting 
commission seemed certain. 

Similar legislation was tabled on the Senate 
floor in 1982, and not considered at the commit- 
tee or other levels in the House. 


Charleston Pediatrician 
Receives Award 

Charleston pediatrician Henrietta Marquis, 
M. D ., has become one of a handful of state resi- 
dents to be honored as a Distinguished West 
Virginian. 

She received the award on December 8 from 
Governor John D. Rockefeller IV during a sur- 
prise ceremony in Charleston at the Capitol 
Building on her 75th birthday. 

Doctor Marquis specializes in child behavioral 
problems. She has practiced in Richwood, 
Beckley and Charleston during her career. 

The award was created by Governor Rocke- 
feller a few years ago. He praised Doctor 
Marquis for her many years of service to 
children in both the public and private sectors. 

A native of Philadelphia, she moved to Rich- 
wood in 1935. In 1977, at the age of 70, she 
accepted a fellowship in child psychiatry at 
WVU Charleston Division. After studying for 
three years, she re-entered private practice. She 
also is a consultant for the adolescent unit of 
Lakin State Hospital. 

Doctor Marquis received her undergraduate 
degree from Cornell University and her M. D. 
from the University of Pennsylvania. 

She said she was overwhelmed by the award. 


CME Program At Marshall 
Gets Accreditation 

The Accreditation Council for Continuing 
Medical Education (ACCME) has granted four- 
year accreditation to the Marshall University 
School of Medicine. 

Charles W. Jones, Ph.D., the school’s Director 
of Continuing Medical Education, said the coun- 
cil looks at the administration, financial stability 
and educational integrity of programs, which can 
be accredited for periods of one to six years. 
Doctor Jones said the four-year period is 
standard. 

“Accreditation by the ACCME indicates to 
the consumer that some national agency has re- 


January, 1983, Vol. 79, No. 1 


21 


viewed the program and given its assurance that 
we know how to evaluate continuing medical 
education offerings and are able to screen them 
for quality,” he added. 

In the past year, the school’s continuing medi- 
cal education program has served health pro- 
fessionals from 41 West Virginia counties and 
22 other states. 

As a new medical school, Marshall previously 
had had a two-year provisional accreditation. 


State Funds Needed To Keep 
Air Rescue Program 

State funds totalling $3.73 million in 1983 
are being sought for the full implementation of 
an air medical rescue program which was started 
on an experimental basis last July. 

The West Virginia State Police MEDEVAC 
project, conducted in 26 counties during the pilot 
program, expires, along with its funding, this 
month. 

The program was put together jointly by the 
West Virginia Department of Public Safety and 
the Office of Emergency Medical Services in the 
State Health Department. The two departments 
now are enlisting the aid of the medical com- 
munity in securing the needed state money. 

The program provides rapid transfer of criti- 
cal patients from general care medical facilities 
to specialty care centers. Currently, the State 
Police Aviation Division has two Bell jet heli- 
copters which are manned by three pilots, hut 
missions are limited to daylight hours and mini- 
mum acceptable weather conditions. 

27 Missions Completed 

“To date there have been a total of 49 requests 
for this air support link to the Emergency 
Medical Service System, and 27 missions have 
been completed,” said Samuel W. Channell, 
Associate Director of the Office of Emergency 
Medical Services. “We are finding that there is 
indeed a real need for this service, especially 
for critical patients in our more rural general 
hospitals.” 

In order to serve the entire state, the needs 
include: sufficient funds for the acquisition of 
two larger, twin-engine, all-weather helicopters; 
necessary ground support; and six State Police 
paramedics and six additional State Police 
pilots. 

State Police Chief Fred Donohoe is scheduled 
to talk to physicians about the MEDEVAC pro- 
gram on Saturday, January 22, during the 16th 
Mid-Winter Clinical Conference in Charleston. 


Medical Meetings 


Jan. 10-12 — Am. Society for Laser Medicine & Sur- 
gery, New Orleans. 

Jan. 20-22 — Neurosurgical Societies of the Virginias, 
Hot Springs, VA. 

Jan. 21-23 — 16th Mid-Winter Clinical Conference, 
Charleston. 

Jan. 29-Feb. 3 — Am. College of Allergists, New Or- 
leans. 

Feb. 8-12 — Am. College of Emergency Physicians, 
Surgery/Trauma, Detroit. 

Feb. 11-13 — Biomedical Topics in Psychiatry (Medi- 
cal College of VA), Hot Springs, VA. 

Feb. 18-20 — Regional CME Meeting, Am. College of 
Physicians, Alexandria, VA. 

March 4-6 — Am. Medical Student Assoc., Cleevland. 

March 10-15 — Am. Academy of Orthopedic Sur- 
geons, Anaheim, CA. 

March 20-24 — Am. College of Cardiology, New Or- 
leans. 

March 25-26 — Infection Control Workshop (Monon- 
gahela General Hospital, WVU School of Medi- 
cine), Morgantown. 

April 15-17 — WV Chapter, AAFP, Morgantown. 

April 17-21 — Am. Urological Assoc., Las Vegas. 

April 17-22 — Operative Treatment of Fractures & 
Nonunions (Johns Hopkins University), Hot 
Springs, VA. 

April 18-22 — Am. Roentgen Ray Society, Atlanta. 

April 24-28 — Am. Assoc, of Neurological Surgeons, 
Washington, D. C. 

May 4-7 — WV Chapter, Am. College of Surgeons, 
White Sulphur Springs. 

May 8-12 — Am. College of Obstetricians & Gyne- 
cologists, Atlanta. 

May 13-14 — Topics in Cardiovascular Diseases (Am. 
Heart Assoc.), Baltimore. 

June 19-23 — Annual Meeting of AMA House, Chi- 
cago. 

Aug. 25-27 — 116th Annual Meeting, W. Va. State 
Medical Assn., White Sulphur Springs. 

Sept. 29-Oct. 2 — Am. Society of Internal Medicine, 
San Francisco. 

Oct. 9-14 — Am. College of Surgeons, Atlanta. 


22 


The West Virginia Medical Journal 



IF YOU LOOKED AT THE NEW 
1983 SAAB SEDAN THE WAY WE DO, 
YOU’D CALL IT BEAUTIFUL, TOO. 



Just look at the things that really matter. 

For example, the new Saab’s backseat folds down to provide 53 cubic 
feet of cargo space— more than any other sedan in America. 

The 1983 Saab’s fuel-injected engine gives you the muscle of 6 or 8 
cylinders, but does it with just 4. 

And because the Saab has front-wheel drive, you experience superior 
handling and stability, even during inclement weather. 

And the list goes on. 

If, however, you’re still not convinced that the new Saab Sedan is one 
of the most beautiful cars in the world, 
you’ll simply have to come by and take 

a test drive. THE MOST INTELLIGENT CAR 

And see for yourself. EVER BUILT. 


WVU Medical Center 
—News- 



Compiled from material furnished by the Medical Center 
News Service, Morgantown, W. Va. 


Prehistoric Gene Works 
‘Too Well’ Today 

Diabetes is often caused by a “thrifty” gene 
that in prehistoric times may have helped people 
survive but now tends to make them obese and 
subject to heart attacks. 

Two WVU researchers, Drs. Margaret J. 
Albrink and Irma H. Ullrich, are conducting 
studies to determine the best kind of diet to 
combat the effects of this misguided gene. 

“Diabetes is very strongly genetically de- 
termined,” Doctor Albrink said. “Yet it is very 
common, especially the adult-onset variety or 
Type II. To be both common and genetic, it 
must have had survival value in past ages. 

“The theory is that in those times food was 
scarce and a person might have to go for days 
without a meal. There would be survival value 
in having this thrifty gene to enable you not 
to spend too much energy, but to conserve it. 

Result Obesity 

“But when a creature who is genetically good 
at conserving energy is suddenly and regularly 
fed a lot, the result is obesity and the ailments 
that often go with it, including diabetes,” she 
said. 

Doctor Albrink, who is President of the West 
Virginia Affiliate of the American Diabetes As- 
sociation, said one in every 20 Americans is 
believed to have diabetes, and that half of the 
cases are undiagnosed. 

“Almost all individuals with undiagnosed 
diabetes are overweight adults with non-insulin- 
dependent or Type II diabetes,” she said. 
“Diabetics are twice as prone to heart disease 
and stroke, and the disease, with its complica- 
tions, is the third leading cause of death by 
disease in this country.” 

Doctor Ullrich noted that while Type-I 
“juvenile” diabetes requires insulin injections or 
pills to lower blood sugar, Type II diabetics 

xii 


“may actually be made worse by insulin treat- 
ment in some cases.” 

“The reason is that insulin is a fattening 
hormone, and weight loss is what many of these 
patients urgently need. ' she said. 

In addition to the dietary studies being con- 
ducted by Doctors Albrink and Ullrich, WVU 
Medical Center researchers are working with 
other phases of diabetes. One of the most im- 
portant involves gluconeogenesis, or how the 
body produces its own blood sugar. 

Doctor Albrink said that more than a dozen 
Diabetes Association chapters around West Vir- 
ginia observed Diabetes Month in November as 
part of a national observance. Runathons, 
bikathons and other fund-raising activities were 
held, with most of the money to be used for 
research and for patient and public education 
about diabetes, she said. 



Dr. Stephen C. Rector, resident in medicine, and 
nurse Leah Heimbach examine an “accident victim” 
during the recent advanced life support trauma 
course at WVU Medical Center. The course, de- 
signed to teach emergency life-saving skills, was 
sponsored by the West Virginia Chapter of the 
American College of Surgeons. Persons portraying 
patients were made up by students from the WVU 
Department of Art. 

The West Virginia Medical Journal 


New Harmarville program helps patients 
control and live with pain. 


Harmarville Rehabilitation Center 
has assigned a special staff and 20- 
bed unit for the exclusive treatment 
of pain. 

This program is achieving some 
dramatic results, particularly with 
back- and neck-injured patients. Over 
90% of all pain program participants 
have shown improved physical func- 
tioning. For those patients whose 
goal was to return to work, over 50% 
achieved this goal. An additional 5% 
of our former patients are under- 
taking vocational training in prepara- 
tion for employment. 

Each pain patient is treated both 
in a group and individually, and the 
patient’s family is deeply involved 
throughout the program. Treatment 
involves physical therapy, biofeed- 
back and relaxation training, educa- 
tion and counseling, and vocational 
programming. Most important, our 


J* 



Harmarville Rehabilitation Center, P.O. Box 


Other special 
Harmarville programs: 

• Neuro-spinal program for the 
rehabilitation of quadriplegics 
and paraplegics. 

• Head injury program for 
cognitive retraining of brain- 
injured patients. 

• Claims Assessment for Rehabil- 
itation Evaluation and Services 
(CARES) for returning injured 
workers to maximum level 
of employment. 


patients are taken off of all addicting 
drugs for pain. 

For more information on Harmar- 
ville... its pain program and admission 
procedures, call John F. Delaney, 
M.D. or Mary Anne Murphy, Ph.D. 
at 781-5700. 



11460, Guys Run Road, Pittsburgh, PA 15238 



Third-Party News, Views 
and Program Concerns 



AMA Complains About Proposed 
Medicare Regulations 

The American Medical Association recently 
urged Richard Schweiker, Secretary of the U. S. 
Department of Health and Human Services, to 
give his personal attention to proposed regula- 
tions that would alter Medicare reimbursement 
systems for physicians and interfere with con- 
tractual relationships between institutional pro- 
viders and physicians. In a letter to the Secre- 
tary, AMA Executive Vice President James H. 
Sammons, M. D., said “many elements of the 
proposal are arbitrary and outside of the author- 
izing statute.” 

The regulations, proposed by the Health Care 
Financing Administration (HCFA) to imple- 
ment Section 1887 of the Social Security Act, 
would establish criteria and maximum limits on 
reimbursement for physicians’ services furnished 
to Medicare beneficiaries by “provider-based” 
physicians. The letter to Schweiker included the 
AMA’s November 5 statement to HCFA calling 
for withdrawal of the proposed rules. 

Statute Authorizations 

The statute authorizes regulations to dis- 
tinguish between physician services provided to 
individual patients and those services that are 
provided for the “general benefit . . . (of) pa- 
tients in a hospital or a skilled nursing facility” 
for the purpose of allocating the cost of physi- 
cian services between Medicare Part A and Part 
B. It also authorizes establishment of “reason- 
able compensation equivalents” that are to be 
applied as the maximum Medicare reimburse- 
ment for services furnished for the general bene- 
fit of the patient population. 

In its statement, the AMA said the proposed 
regulations broaden the statute by extending 
reasonable compensation equivalents to Part B, 
whereas the law states that this system is to 
apply to professional services rendered for the 
general benefit of patients (Part A). The AMA 
said the rule would set limitations on anesthesi- 
ology and radiology services that are not author- 

xiv 


ized by law and would inappropriately deny 
Medicare reimbursement under Part B for clini- 
cal pathology services. 


Compensation Fund Stresses 
Consultation Policy 

Workmen’s Compensation Commissioner 
Gretchen 0. Fewis has called new attention to 
the Compensation Fund’s policy regarding con- 
sultations requested by physicians. The policy 
first was set forth in The Journal in October, 
1980. 

The Fund continues to feel that the policy 
facilitates more timely medical care for injured 
workers; eliminates administrative paperwork 
and delay in the Fund as well as in doctors’ 
offices; and permits, from the agency’s view- 
point, better claims management. 

The policy, set forth below, did not change 
a procedure stipulating that prior authorization 
be requested for a change of treating physician; 
treatment by other than the physician of record, 
and hospitalization /surgical intervention. 

Here, again, is the material provided earlier: 
NEW CONSUFTATION POLICY 
Effective November 1, 1980 

If, in the opinion of the treating phy- 
sician of record, a consultation (examina- 
tion only ) is deemed advisable in relation 
to the compensable injury, the treating phy- 
sician may, without prior authorization, 
arrange the consultation, provided the con- 
sulting physician is located within 100 miles 
of the claimant’s residence. However, the 
treating physician, upon arranging the con- 
sultation, must immediately notify the fund 
of the referral by narrative report outlining 
the claimant’s condition and the reason a 
consultation is desired. It also is necessary 
that the consultant provide the Fund with a 
narrative report of the findings and recom- 
mendations. 

The West Virginia Medical Journal 


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Henrietta L. Marquis, M. D. 925-3160 
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• Staffed by Qualified Psychiatrists and 
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• Schooling Provided on Children’s Pa- 
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• Serving the Community for Over 25 
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January, 1983. Vol. 79, No. 1 


xv 


Obituaries 


CLARK K. SLEETH, M. D. 

Dr. Clark K. Sleeth, former Dean of the West 
Virginia University School of Medicine and a 
key figure in its development and growth, died 
on November 30 in a Morgantown hospital. He 
was 69. 

Doctor Sleeth had been a member of the 
University faculty for more than 40 years. From 
1961 until 1970, he served as Dean of the Medi- 
cal School, which awarded its first doctorates in 
1962. 

After stepping down as Dean, Doctor Sleeth 
organized the University's Department of Family 
Practice in the early 1970s, and served as its 
Acting Chairman until 1973. 

Doctor Sleeth, a member of the State Medical 
Association’s Committee on Medical Scholar- 
ships since 1960, coordinated the scheduling of 
the Committee’s annual interviews of beginning 
medical students for West Virginia medical 
school scholarships awarded each year by the 
Association. His service to the Committee con- 
tinued beyond retirement in 1978 and included 
the 1982 meeting of the Committee last summer. 

Born in Logansport, Marion County, Doctor 
Sleeth was graduated from WVU, and received 
his M. D. degree in 1938 from the University 
of Chicago. He took his internship and resi- 
dency at the Henry Ford Hospital in Detroit. 

He was a student of, and later a co-worker 
with, the late Dr. Edward J. Van Uiere, con- 
sidered the father of the four-year School of 
Medicine. He succeeded Doctor Van Liere as 
Dean. 

During Doctor Sleeth’s tenure, the School's 
graduating classes more than doubled, and it 
joined tbe ranks of leading centers for medical 
education and research. 

As a physiologist and pathologist, Doctor 
Sleeth was author or co-author of some three 
dozen research papers. 

A Professor Emeritus since his retirement, 
Doctor Sleeth continued working on several pro- 
jects, including an updated history of the WVU 
Medical School faculty. 

He was an honorary member of the Monongalia 
County Medical Society, West Virginia State 
Medical Association, and American Medical As- 
sociation. 

Doctor Sleeth was President of the Monongalia 
County Medical Society in 1951, and Eirst Vice 


President of the State Medical Association in 

1952. 

Survivors include the widow; three daughters, 
Mrs. Hubert A. Shaffer, Jr., of Charlottesville, 
Virginia, Mrs. Jerry L. Creamer of Dallas and 
Mrs. David M. Fulton of Charleston, South 
Carolina; one sister, Mrs. Louis Hagan of 
Wheeling, and one brother, Charles R. Sleeth of 
Madison, New Jersy. 

♦f W # 

BERNARD ZIMMERMANN, M. D. 

Dr. Bernard Zimmermann, who organized and 
for 13 years headed the Department of Surgery 
at the West Virginia Efniversity School of Medi- 
cine, died on December 4 in a Morgantown 
hospital. He was 61. 

Doctor Zimmermann was the first person to 
be named chairman of a clinical department in 
preparation for the 1960 opening of LIniversity 
Hospital, which marked the actual beginning of 
WVU's four-year School of Medicine. He then 
was Professor of Surgery at the University of 
Minnesota Medical School. 

In 1971, he was elected President of the 
Halsted Society, named for the father of modern 
surgical techniques and including some 150 
leading educators in surgery and allied branches. 

In 1973, Doctor Zimmermann resigned as 
Chairman of Surgery and returned to full-time 
teaching, research and operative surgery. The 
following year, an international group that in- 
cluded several of his former chief residents 
organized the Bernard Zimmermann Surgical 
Societv. which sponsored lectures and prizes for 
outstanding students. 

Doctor Zimmermann. a native of St. Paul, 
Minnesota, received both his undergraduate and 
M. D. I 1945 ) degrees from Harvard University. 
He interned at Boston City Hospital and, in 

1953, earned a Ph.D. degree ( Doctor of 
Philosophy in Surgery ' from the University of 
Minnesota. 

A Navy veteran, he also was a member of 
the American Surgical Association. American 
College of Surgeons, National Society for Medi- 
cal Research. Monongahela County Medical 
Society, and West Virginia State Medical As- 
sociation. 

In 1981, a portrait in tribute to Doctor 
Zimmermann was placed in tbe Medical Center. 

Survivors include the widow; two sons, 
Bernard Zimmermann III of Swansea, Massa- 
chusetts, and Andrew Zimmermann of Somer- 
ville, Massachusetts; a sister, Mrs. Walter 
Limbach of Pittsburgh; and a cousin, Charlotte 
Nelson Smith of St. Paul. 


xvi 


The West Virginia Medical Journal 


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County Societies 


CENTRAL WEST VIRGINIA 

Dr. Harry Shannon of Parkersburg, President 
of the State Medical Association, addressed the 
meeting of the Central West Virginia Medical 
Society on October 28. 

The meeting was held at the Bicentennial 
Motel in Buckhannon. 

Other guests include Dr. Tom Stahly, a new 
radiologist from Summersville; Charles R. Lewis 
of Charleston, Executive Secretary of the State 
Medical Association, and Mrs. Richard S. 
(Linda) Kerr of Morgantown, President of the 
Auxiliary to the State Medical Association. 

It was reported that the Cowen water supply 
has been fluoridated. 

The Society elected new officers. — Joseph B. 
Reed, M. D., Secretary-Treasurer. 

» • » 

WESTERN 

The Western Medical Society met on Novem- 
ber 9 in Spencer at Roane General Hospital. 

The guest speaker was Dr. Harry Shannon of 
Parkersburg, President of the State Medical As- 
sociation. 

Doctor Shannon gave a very interesting talk 
about involvement of individual members of the 
Medical Society in health care, and also dis- 
cussed the present status of malpractice insurance 
and cases in West Virginia in comparison with 
other states. A question-and-answer period fol- 
lowed. 

New officers were elected. — Ali H. Morad, 
M. D., Secretary-Treasurer. 

• * * 

McDowell 

The McDowell County Medical Society met 
on November 10 at Stevens Clinic Hospital in 
Welch. 

Following a pot-luck dinner arranged by the 
Auxiliary, there was a short presentation on 
domestic violence presented by Norman Googel 
and Associates from McDowell County. 

It was reported that a poll of the Society was 
favorable for the support of an extended care 
facility in the County. The request for support 


had come from the Imperial Construction Com- 
pany. 

New officers were elected. — Muthusami 
Kuppusami, M. D., Secretary. 

* * # 

BOONE 

The Boone County Medical Society met on 
November 30 at the Boone County Health 
Center, a new nursing home. 

Officers for 1983 were elected, and three new 
members practicing in Madison were admitted. 

The Society has chosen the second Tuesday 
of each month for its meeting date and con- 
tinuing medical education. — Manuel T. Uy, 
M. D., Secretary-Treasurer. 


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xx 


The West Virginia Medical Journal 



The West Virginia Hedical Journal 

Vol. 79, No. 2 February, 1983 

Metastatic Cancer Of Unknown Origin: Ohio Valley 
Medical Center Experience 


GURIJALA N. REDDY, M. D. 

Department of Radiation Oncology, Ohio Valley 
Medical Center, Inc., Wheeling, West Virginia; and 
Clinical Assistant Professor of Radiology, West Virginia 
University School of Medicine 


One hundred and fifty-one patients with 
metastatic carcinoma from an unknown primary 
site were treated from 1969 to 1980 at Ohio 
l' alley Medical Center [OVMC), Inc., Wheeling, 
West Virginia. Diagnosis, survival and prognosis 
of these patients are discussed. 

ATetastatic cancer of unknown origin is more 
frequently encountered in clinical practice 
than it was once believed. It constitutes 10 to 
15 per cent of all cancer cases, and is a diag- 
nostic and therapeutic challenge. Many articles 
have been published on the subject with reference 
to diagnosis and treatment, but the emphasis on 
investigating a patient with an occult primary 
cancer site is shifting from an aggressive to a 
conservative approach. It is evident from the 
literature that all types of metastatic cancer 
(different sites and histological varieties) with 
undetermined primary sites are not the same. 
For example, metastatic squamous carcinoma in 
the upper neck nodes should be worked up and 
treated differently from squamous or adenocarci- 
noma in the supraclavicular area or in the bone. 
The former usuallv has a better prognosis than 
the latter. Such patient material from OVMC 
is reviewed here with reference to survival, and 
a plea is made for judicious use of diagnostic 
methods. Because lymphomas constitute a dif- 
ferent entity, they are excluded from this review. 


Materials and Methods 

OVMC Tumor Registry was searched for 
patients with metastatic carcinoma at single or 
multiple sites whose primary site could not be 
determined. There were 151 patients from 1969 
to 1980 with histologically-proven diagnosis. In 
only five of these patients was histological 
diagnosis made at autopsy. Of the 151 patients. 
89 were males and 62 were females. Ages ranged 
from 34 to 90 years, with a majority of patients 
being 60 or older. There were an additional 51 
patients who would have been included in this 
study except for a lack of histological confirma- 
tion of diagnosis. 

The presenting sites of metastatic cancer are 
listed in Table 1. The most common single site 
of mestastases was the lymph nodes, followed 
by the bone. Adenocarcinoma and undifferenti- 
ated carcinoma were the most common cell types 
as shown in Table 2. All patients bad complete 


TABLE 1 

Presenting Site of Metastatic Cancer 


Site 

No. of Patients 

Lymph Nodes 

38 

Bone 

25 

Abdomen 

19 

Liver 

17 

Brain 

8 

Lung 

6 

Generalized 0 

10 

Other 

28 

TOTAL 

151 


° More than one site at diagnosis 


February, 1983, Vol. 79, No. 2 


23 


TABLE 2 
Histology 


Type 

No. of Patients 

Squamous 

25 

Adeno Ca 

44 

Undiff. Ca 

42 

Unspecified Ca 

31 

Cytology 

3 

Other 

6 

TOTAL 

151 


histories recorded and physicial examinations 
performed. Their metastatic workups included 
a wide variety of hematological, biochemical, 
roentgenographic, isotopic, invasive and non- 
invasive x-ray studies as well as endoscopic 
examinations. In only a few of the patients 
could the primary site be determined. 

Survival figures are rather grim; however, 
they are consistent with other published reports. 
Thirty per cent of these patients died within 
one month, and 80 per cent died within one year 
after the diagnosis was made. Only 20 per cent 
survived for one year or longer. The majority 
of the latter group were squamous carcinomas 
metastatic to upper neck nodes. These patients 
usually have a better prognosis than those with 
other metastases in other sites. Five patients 
were lost to follow-up and were counted as dead 
of cancer. Thirteen patients are alive at the time 
of this report. 

Autopsy was performed on 13 patients. Of 
these, the primary site was found in only six — 
two lung and one each pancreas, ovary, kidney 
and rectum. In the remaining seven cases, the 
primary site of malignancy could not be de- 
termined. 

Fifty-one other patients, 28 males and 23 
females, with clinical and x-ray diagnosis but 
without histological confirmation, had equally 
poor or worse survival. Ninety per cent of these 
patients died within one year from the time of 
clinical diagnosis. 

Adequate testing and appropriate treatment 
did not seem to influence the survival of these 


TABLE 3 
Mortality 



1 Month 

1 2 Months 


No. of Patients 

No. of Patients 

With Histology 

45/151 

30% 

121/151 80% 

Without Histology 

29/51 

58% 

46/ 51 90% 


TABLE 4 

Survival — Review of Literature 



Total No. 
Patients 

% 

Living 

Time After 
Dx - Month 

Moertel et al 4 

150 

10 

14 

Stewart et alA 

87 

12 

12 

Richardson et al. 2 

86 

12 

12 

Reddy 2 

151 

20 

12 


1 Adeno Ca only 

2 All cell types (including neck node metastases) 


patients. No attempt is made to analyze the in- 
vestigations in detail. 

Discussion 

Many reports in the literature reveal that the 
survival of the patients with metastatic carci- 
noma whose primary site is unknown is poor 
(Table 4). Moertel et al. 1 from the Mayo Clinic 
reported 10-per cent survival at 14 months in 
150 patients with metastatic adenocarcinoma of 
unknown origin treated with various chemo- 
therapeutic agents. Richardson and Parker 2 re- 
ported 86 patients with unknown primary 
malignancy: 50 per cent died within three months 
and, by one year, 12 per cent remained alive. 

Nystrom et al . 3 reported 266 patients with 
metastatic cancer from an occult primary site. 
An excellent review of diagnostic testing in this 
study revealed that only 8/218 (3.6 per cent) 
upper gastrointestinal tract contrast roentgeno- 
grams, 9/198 (4.5 per cent) full column barium 
enema examinations, and 5/187 (2.6 per cent) 
intravenous pyelograms were true positive re- 
sults. This is a very low yield rate indeed. The 
authors also had many false positive results, and 
advocate use of these tests with specific organ 
dysfunction or clinical suspicion of abnormality. 

Stewart et al. 4 from Sydney, Australia, re- 
ported 87 patients with malignancy from un- 
known primary site. The primary site could be 
determined in only eight patients after extensive 
workup. Median survival was 13 to 14 weeks. 
Only 12 per cent were alive at 12 months (esti- 
mated from graph ) . Because of the low yield 
rate and little influence on survival, they recom- 
mend fewer investigations as warranted by 
the individual patient’s situation. 

Steckel and Kagan 5 reported from the Uni- 
versity of California, Los Angeles 253 patients 
with unknown primary site of malignancy 
initially. In 34 autopsies no primary site could 
be found in 20 cases and, of the remaining 14, 
seven patients had lung cancer. They com- 


24 


The West Virginia Medical Journal 


merited that “long and arduous diagnostic ex- 
aminations may he pointless academic exercise.” 

Workup Not Rewarding 

Based on the present survival figures and re- 
view of the literature, it is evident that extensive 
diagnostic workup is not likely to be rewarding 
in locating the primary cancer site. Even if it 
is located it will have little influence on the 
treatment (with very few exceptions) and on 
prolonging the survival of the patients. When 
approximately 90 per cent of these patients are 
expected to die of cancer within one year, putting 
them through expensive, time-consuming and 
uncomfortable diagnostic tests may not be justi- 
fied. 

By definition, metastatic disease in various 
sites, except in some neck nodes, is a stage IV 
disease which carries poor prognosis no matter 
where the primary is located. Metastasis is 
usually by hematogenous and, occasionally, 
lvmphatic spread, suggesting generalized disease 
even though metastasis to only one site may be 
obvious at initial diagnosis. The majority of 
these patients are treatable by surgery, radiation 
therapy or chemotherapy, but are incurable. 


By no means should any test that is likely 
to improve the patient’s comfort and survival be 
withheld on the pretext of poor prognosis; how- 
ever, blind and frantic search for primary loca- 
tion of cancer in every patient is discouraged. 
Patients do deserve special attention and ade- 
quate treatment, even for palliation, which should 
be highly individualized because of a wide 
variety of histological types and locations at 
initial diagnosis. 

References 

1. Moertel CG, Reitemeier RJ, Schutt AJ, Hahn RG: 
Treatment of the patient with adenocarcinoma of un- 
known origin. Cancer 1972; 30:1469-72. 

2. Richardson RG, Parker RG: Metastases from un- 

detected primary cancers. West J Med 1975; 123:337- 
339. 

3. Nystrom JS, Weiner JM, Wolf RM, Bateman JR, 

Viola MV : Identifying the primary site in metastatic 

cancer of unknown origin. JAMA 1979; 241:381-83. 

4. Stewart JF. Tattersall MHN, Woods RL, Fox RM: 

Unknown primary adenocarcinoma: Incidence of over- 

investigation and natural history. Br Med J 1979; 
1(6177): 1530-1533. 

5. Steckel RJ, Kagan AR: Diagnostic persistence in 

working up metastatic cancer with an unknown primary 
site. Radiology 1980; 134:367-369. 


To be engaged in opposing wrong affords but a slender guarantee for 
being right. 


— William Gladstone 


February. 1983, Vol. 79, No. 2 


25 


Epikeratophakia : A New Treatment For Corneal 
Irregularity And Keratoconus 


THEODORE P. WERBLIN, M. D„ Ph.D. 

The Blaydes Foundation , Bluefield, West Virginia 


The technique of epikeratophakia has been 
modified to treat corneal surface irregularity 
I astigmatism ) and keratoconus. A lamellar cor- 
neal graft is sutured tightly in place atop the 
intact recipient cornea. The graft produces a 
flattening of the cornea and facilitates contact 
lens or spectacle correction of vision. 

A case report of a keratoconus patient whose 
preoperative irregular astigmatism was elimi- 
nated and whose myopia was reduced 12 diopters 
is presented here. This procedure has much less 
morbidity than penetrating keratoplasty which 
is the usual treatment for advanced keratoconus. 

To date, corneal graft rejection has not been 
encountered with this procedure. 

\ interior keratoconus is a noninflammatory 
■T*- axial ectasia of the cornea. It becomes 
recognizable at puberty and can progress 
relatively quickly or slowly with stabilization. 
Protrusion of the apex occurs because of thinning 
of the cornea. Clinically, this can be recognized 
by distortion of the curve of the lower lid caused 
by the corneal cone with the eye in down gaze 
(Munson’s sign). Focal disruption of Bowman’s 
layer causes the epithelium to be irregular in 
thickness and the basement membrane to be 
abnormal. When Descemet’s membrane is 
stretched beyond its elastic breaking point, acute 
clouding of the cornea (bydrops) may occur. 
This increase in corneal clouding results from 
profound stromal edema. 

Initial treatment includes the use of a hard 
contact lens to correct vision. This eliminates 
irregular corneal surface (astigmatism), but 
eventually contact lens fitting becomes impos- 
sible because this increasingly irregular corneal 
surface does not allow the lens to stabilize. Many 
cases of advanced keratoconus can be treated 
surgically with either penetrating or lamellar 
keratoplasty; however, penetrating keratoplasty 
may be impossible with large cones that extend 
to near the limbus. This form of surgery has 
the continual risk of graft rejection and cataract 
formation. Lamellar surgery is preferable be- 
cause these risks are minimized or nonexistent. 
Previous forms of lamellar keratoplasty were 


extremely difficult because they required careful 
lamellar dissection over the surface of the cone. 1 

A new approach to the treatment of kerato- 
conus has been developed by modifying the 
technique of epikeratophakia, 2,3,4 a form of 
lamellar refractive surgery. In this procedure, 
donor corneal tissue is lathed in the shape of 
a contact lens and sutured to the anterior surface 
of the recipient cornea. Any optical function 
which a contact lens can perform theoretically 
can he served by these lamellar grafts. For 
keratoconus, a piano lamellar graft ( parallel 
surfaces ) is sutured tightly in place to flatten 
the irregular corneal surface. The residual 
refractive error can be handled with either con- 
tact lenses or spectacles. 

Case Report 

A 33-year-old, white male had had poor vision 
for many years. He was first seen at The Blaydes 
Clinic in 1971, at which time he stated that the 
doctors in the military sendee had diagnosed 
keratoconus. His visual acuity was 20/50 OD 
and 20 / 200 OS, and his keratometer readings 
were 43.00 @ 180° x 41.30 @ 90° OD and 
45.50 @ 180° x 42.00 @ 90° OS. Slit-lamp 
evaluation showed some central thinning in the 
right eye hut no breaks in Bowman’s membrane. 
However, a definite corneal irregularity in the 
left eye with a small amount of central corneal 
opacification and thinning was revealed. The 
cone was located in the infratemporal portion 
of the cornea. 



Figure 1. Preoperative appearance of the cornea. 
The irregularity of the curve of the anterior corneal 
surface and a small apical scar can be seen. 


26 


The West Virginia Medical Journal 


The patient was informed that he might need 
a corneal transplant in the future but was ad- 
vised to try hard contact lenses for the time 
being. The patient wore his contact lenses suc- 
cessfully for 10 years. 

In May, 1981. an ulceration was discovered on 
the apex of the cone in his left eye. His visual 
acuity with contact lenses was 20/25 OD and 
20 300 OS. The patient was then advised not 
to wear his contact lenses. He was treated 
medically, and the ulceration improved. The 
epikeratophakia procedure was explained to him 
when he was seen in June. 1981, because of his 
intolerance to contact lenses. 

The patient's workup revealed the following 
findings: Vision (without correction) 20 80 

OD. 20/300 OS; Vision (with spectacle correc- 
tion ) 20 30 OD, 20 200 OS; Vision (with con- 
tact lenses) 20 20 OD. 20/70 OS; Vision (with 
contact lenses and pinhole) 20/20 OD. 20/25 
OS; Pachometry (stromal thickness) .51 mm 
OD. .43 mm OS and Tension 13 OD. 19 OS. 
His A-Scan readings were 24.57 OD, 24.78 OS, 
and his keratometry readings were 43.25 @ 
75 x 44.25 @ 165 OD and 65.75 @ 20° x 
53.00 @ 110' OS. Minimal apical scarring of 
the cornea was seen in the OS. 

Graft Performed 

The epikeratophakia lamellar graft was per- 
formed on the left eye on August 13, 1981 
(Figure 1). In this procedure the epithelium 
was removed from the recipient cornea with 
absolute alcohol. A small amount of epithelium 
was left remaining in the periphery of the cornea. 
The peripheral cornea was trephined to a depth 
of 0.15 mm (8.0 mm in diameter), and the 
inner edge of the trephine cut excised to create 
a circular bed 0.5 mm wide and 0.15 mm deep. 



Figure 2. Postoperative appearance of the lamellar 
graft at three weeks. A somewhat hazy appearance 
is characteristic of the early postoperative appear- 
ance of these grafts. 


The exposed corneal stroma allows the graft to 
scar securely in place. 

The lenticule ( diameter 8.25 mm) was sutured 
to the recipient cornea ( 8.0-nmi-diameter bed) 
using 20 multiple interrupted 10-0 nylon sutures. 
The graft was sutured under sufficient tension 
to flatten the central corneal cone. A piano 
bandage soft contact lens was used to cover the 
graft and protect the epithelium as it grows 
across the graft. At the time of surgery, the 
postoperative keratometry was 38.50 @ 55" x 
43.75 @ 145°. 

At three weeks, the corneal graft surface was 
completely covered with epithelium, and the 
bandage contact lens was removed. The donor 
corneal graft measured 0.2 mm thick, and the 
recipient measured 0.44 mm (Figure 2). All 
sutures were removed by three months post- 
operatively. At 13 weeks keratometry readings 
were 43.62 @ 21 x 49.62 @ 105 . Visual 
acuity was 20 200 without correction and 20/30 
-1 with spectacle correction (-1.25 -3.50 x 120) 

( Figure 3 ) . 

Discussion 

Penetrating keratoplasty is not always suc- 
cessful in the treatment of keratoconus, particu- 
larly in the case of extensive or displaced cones. 
Penetrating grafts are always subject to immune 
rejection. On the other hand, lamellar grafts, 
although safer, have not had the potential for 
producing 20 20 vision. 1 This is probably due 
to the extensive dissection of the recipient cornea 
and resultant interface scarring. In addition, the 
lamellar dissection is technically very difficult. 

Epikeratophakia is a new form of lamellar 
refractive surgery which avoids this technical 
complexity. In the epikeratophakia procedure, 
the peripheral cornea is trephined to create a 



Figure 3. Three-month appearance of graft. By 
this time, all sutures have been removed and the 
graft has become quite clear. 


February, 1983, Vol. 79, No. 2 


27 



circular bed. This trephine mark allows the graft 
to scar securely in place. The patient’s cornea 
needs no other lamellar dissection. There is no 
manipulation of the thinned area of the cone, 
and the anterior chamber has no chance of being 
penetrated. 

The epikeratophakia technique has been modi- 
fied to produce flattening of the keratoconus 
cornea to facilitate contact lens or spectacle cor- 
rection of vision. This is accomplished by sutur- 
ing the piano lamellar graft tightly in place. 
These lamellar grafts do not seem to undergo 
immune rejection, and thus avoid this major 
complication of penetrating grafts. In addition, 
this technique has produced 20/20 visual acuity 
in keratoconus patients. 4 

Currently, keratoconus lamellar grafts are 
lathed with no refractive power. It is feasible 
that a microkeratome section could be used in 
place of lathed tissue. This would simplify the 
procedure. Donor tissue must be frozen in order 
to be cut on the cryolathe. This kills the 
keratocytes and makes the donor disk a non- 
viable tissue. Microkeratome sectioning would 
allow living tissue to be used. This may speed 
the visual recovery of the recipient eye. 


Improves Three Major Problems 

The treatment of keratoconus with epiker- 
atophakia grafts was designed to improve the 
three major visual problems associated with this 
condition: myopia, regular astigmatism and 
irregular astigmatism. Postoperatively, the pa- 
tient in this case study has shown less myopia 
and cylinder compared to preoperative values, 
and has lost the irregular astigmatism character- 
istic of keratoconus. The residual astigmatism 
and myopia also theoretically could be treated 
with these lamellar grafts. Experimental ap- 

proaches to these complex optical problems cur- 
rently are under investigation. 

Reference 

1. Malbran E: Lamellar keratoplasty in kera- 

toconus, in King JH, McTigue JN (eds): The Cornea- 
World Congress, Washington, DC, Butterworth, 1965. 
p 511. 

2. Werblin TP, Kaufman HE: Epikeratophakia: The 
surgical correction of aphakia. II. Preliminary results in 
a non-human primate model. Curr Eye Res 1981; 1:131- 
137. 

3. Werblin TP, Kaufman HE, Friedlander MH, 
Granet N: Epikeratophakia: The surgical correction of 
aphakia. III. Preliminary results of a prospective clinical 
trial. Arch Ophthalmol 1981; 11:1957-1960. 

4. Kaufman HE, Werblin TP: Epikeratophakia: A 

form of lamellar keratoplasty for the treatment of kera- 
toconus. Submitted to Am J Ophthalmol. 


28 


The West Virginia Medical Journal 


Tension Pneumothorax During Anesthesia* 


STEPHEN T. PYLES, M. D. 

Resident in Anesthesiology, University of Florida, 
Gainesville 

DAVID A. HAUGHT, M. D. 

Huntington, West Virginia, Clinical Professor of 
Surgery, Marshall University School of Medicine, 
Huntington 

ELMER T. VEGA, M. D. 

Huntington, Clinical Associate Professor of Surgery, 
and Coordinator, Section of Anesthesiology, MU School 
of Medicine 

EDUARDO A. RIVAS, M. D. 

Huntington, Clinical Instructor in Surgery, MU School 
of Medicine 


Two cases of tension pneumothorax occurring 
shortly after the induction of general anesthesia 
are presented. Each complication was linked to 
the improper use of an accessory anesthetic 
ventilator valve known as the ventilator-mounted 
switch valve. 

'T'ension penumothorax directly attributable to 
the improper attachment of the anesthesia 
circuit to a directional valve on the ventilator 
known as the “ventilator-mounted switch valve” 
has been described. 1 This device (Figure 1), 
however, still can be found on many anesthesia 
ventilators, and continues to be causative in the 
production of tension pneumothorax during 
anesthesia. 

Case One 

A 68-year-old female was scheduled for repair 
of a herniated lumbar disc. Her blood pressure 
was 138 80 mmHg, pulse 82/minute and respi- 
rations 16/minute. Anesthesia was induced using 
sodium pentothal. Succinylcholine was given to 
facilitate endotracheal intubation. An en- 
dotracheal tube was placed without difficulty, 
and breath sounds were found to be clear and 
equal bilaterally. Vital signs remained stable 
throughout the induction period. The patient 
subsequently was turned to the prone position 
on the operating table where her breath sounds 
were checked again and found to be normal. 

The ventilator tubing was then accidentally 
connected to the ventilator-mounted switch 

“This paper was written while Doctor Pyles was a 
surgical resident at Marshall University School of Medi- 
cine, Huntington, West Virginia. Reprint requests may 
be directed to Doctor Pyles. 


valve post usually occupied by a reservoir 
bag. Tachycardia, hypotension, and subcutaneous 
emphysema occurred within the minute. The 
patient was immediately disconnected from the 
ventilator, and a loud rush of air was heard 
coming from the endotracheal tube. A chest 
x-ray showed a large pneumothorax, mediastinal 
shift, and subcutaneous emphysema I Figure 2). 
Chest tubes were placed and recovery was un- 
eventful. 

Case Two 

A 52-kilogram, 16-year-old female was sched- 
uled for an appendectomy. On arrival in the 
operating room she was afebrile, with a blood 
pressure of 126 80 mmHg, a pulse of 84 per 
minute and a respiratory rate of 14 per minute. 
She had no history of medical problems. In- 
duction of anesthesia was uneventful. D-tubo- 
curarine pre-treatment was followed by sodium 
pentothal 220 mg. and succinylcholine 80 mg. 
An endotracheal tube was inserted with ease. 
The breath sounds were clear and equal bilateral- 
ly prior to connecting the patient to the venti- 
lator. 

Shortly after the initiation of mechanical 
ventilation the surgeon complained that the blood 



Figure 1. The ventilator-mounted switch valve 
with arrows indicating the internal channels. 


February, 1983, Vol. 79, No. 2 


29 


was dark. The chest was noted to be hyper- 
inflated and motionless. The ventilator cycled 
as usual without corresponding chest wall move- 
ment. The endotracheal tube was disconnected 
from the circuit and a large volume of air rushed 
from the tube. One hundred-per cent oxygen was 
given by manual-assisted ventilation. Lung 
compliance was noted to be poor; however, vital 
signs were satisfactory with a blood pressure of 
100/60 and a pulse of 100-110 per minute. 
Breath sounds were diminished on the right side. 
A recovery room chest x-ray demonstrated a 30- 
per cent penumothorax on the right. A chest 
tube was placed and recovery was uneventful. 

Discussion 

In a study by Cooper et al., 2 19.5 per cent of 
all anesthesia misadventures were categorized as 
“ventilator/breathing circuit” problems. 

Each patient presented developed a tension 
pneumothorax secondary to the improper con- 
nection of the anesthesia circuit to the ventilator- 
mounted switch valve (Figures 3 and 4). The 



Figure 2. Patient number one. Portable post- 
induction chest x-ray in operating room. Note large 
left tension pneumothorax with mediastinal shift. 


ventilators continued to cycle without delivering 
their volume to the patients and without audible 
changes in their operation. The lungs were over- 
distended to the point of rupture by anesthetic 
gases flowing directly into a patient’s lungs 
through a closed system. Inadvertent build-up 
of pressure within the ainvay occurs when 
there is a continuous flow of anesthetic gases 
into the trachea with an obstruction to out- 
flow. Modern anesthetic machines are capable 
of delivering pressures in excess of 4000 cm 
Hl'O directly to the trachea when a cuffed 
endotracheal tube is in place. 3 

A medical device alert was distributed by 
Ohio Medical Products on December 8, 1981. 
In their letter they state, “AFTER CAREFUL 
REVIEW, WE STRONGLY URGE THAT THE 
USE OF THESE VALVES BE DISCONTINUED 



Figure 3. This photo demonstrates the ventilator 
tubing improperly attached at the reservoir bag 
port. Note that the stopcock is directed horizontally. 
In this situation gas flows from the anesthesia ma- 
chine, fills the ventilator tubing and is blocked by 
the stopcock. Anesthetic gases continue to flow 
into the patient’s lungs through a closed system, 
resulting in pneumothorax. The ventilator cycles 
normally, delivering its volume directly into the 
room through the open port. 


30 


The West Virginia Medical Journal 



Figure 4. The ventilator-mounted switch valve 
shown with stopcock directed vertically. This posi- 
tion allows manual ventilation without disconnect- 
ing ventilator tubing. The vertical post is the bag 
port, and the horizontal post is the ventilator tubing 
port. 


IMMEDIATELY AND THAT THESE VALVES 
BE PROMPTLY REMOVED FROM THE 
VENTILATORS AND DISPOSED OF IN A 
PROPER MANNER. WE SUGGEST STRIKING 
THE ENDS WITH A HEAVY OBJECT TO DE- 
FORM. RENDERING THE VALVE INOPERA- 
TIVE.” 

Summary 

Two cases of tension pneumothorax occurring 
during anesthesia are presented. These compli- 
cations could have been prevented if either the 
ventilator-mounted switch valve had been used 
correctly or the breath sounds had been recheck- 
ed immediately after connecting the patient to 
the ventilator. 

The anesthesia ventilator-mounted switch 
valve continues to be associated with anesthesia 
morbidity, specifically tension pneumothorax. 
The continued use of this device should be 
seriously questioned. We recommend immediate 
removal of the ventilator-mounted switch valve 
from all anesthesia ventilator systems. 

References 

1. Sears BE, Bocas ND: Pneumothorax resulting from 
a closed anesthesia port. Anesthesiology 1977; 47:311- 
313. 

2. Cooper JB, Newbower RS, Long CD, McPeek B: 
Preventable anesthesia mishaps: A study of human fac- 
tors. Anesthesiology 1978; 19:399-406. 

3. Newton NI, Adams AP: Excessive airway pressure 
during anesthesia. Plazards, effects, and prevention. 
Anaesthesia 1978; 33:609-699. 


February, 1983, Vol. 79, No. 2 


31 



From the Wesl Virginia University 
Medical Center 

Edited By 

Irma II. Ullrich, M. D. 

Associate Professor of Medicine 

Relapsing Polychondritis 


Case Presentation: 

TIMOTHY COOLEY, M. D. 

Resident in Medicine 

Discussant: 

ROXANN POWERS, M. D. 

Assistant Professor of Medicine, Section of 
Comprehensive Medicine 


Relapsing polychondritis, once thought to be a 
rare disease, is being reported with increasing 
frequency. It is a characteristic systemic disease 
which involves primarily cartilaginous tissue with 
an inflammatory and destructive process. It oc- 
curs equally in both sexes with a maximum fre- 
quency in the fourth decade. The most common 
clinical features are: bilateral auricular chron- 
dritis, non-erosive sero-negative inflammatory 
polyarthritis, nasal chondritis, ocular inflamma- 
tion, respiratory tract chondritis , and audioves- 
tibular damage. 

The diagnosis is based primarily on the clini- 
cal features ivith three or more of the above or 
one of the above plus histologic confirmation 
considered adequate. Fifty per cent present with 
auricular chondritis or the arthropathy . Labora- 
tory and radiologic studies are of help mainly to 
rule out other possibilities. Corticosteroids are 
generally the drug of choice with recent reports 
of success with dapsone. 

The mortality rate is reported from 22 per 
cent to 30 per cent with about half of the deaths 
due to respiratory involvement. Although the 
etiology is unknown, there is a frequent associa- 
tion with other rheumatic diseases. An autoim- 
mune cause also is postulated. 


Case Presentation 

Doctor Cooley: 

M.C. is a 64-year-old white male with a six- 
month history of weakness, fatigue, anorexia, 
a 15-pound weight loss and vague antero-lateral 
chest wall pain. He also complained of worsening 
dyspnea on exertion, orthopnea and pedal edema. 
Over the month prior to admission, he had noted 
nightly low-grade fevers not associated with 
chills. He was otherwise asymptomatic. 

Physical examination on admission showed a 
cachectic, chronically-ill-appearing middle-aged 
male. Vital signs: BP of 100/60 mm Hg, pulse 
of 92. respiration of 30, and temperature of 36.8° 
C. The chest examination revealed dullness to 
percussion, decreased breath sounds and de- 
creased tactile fremitus at both bases, diffusely 
scattered rhonchi and point tenderness over the 
left ribs. The cardiac examination was normal. 
The liver had a span of 14 cm.; the spleen was 
not palpable. Rectal examination showed heme 
negative stool. The lower extremities had 2 + 
edema. Neurological examination was remark- 
able only for depression and tearful affect. 

Laboratories on admission: WBC was 10,100 
with a normal differential; Hb, 9.3 gms; Hct, 
28 per cent with normal indices; platelet count. 
329,000; ESR. 126/hr: electrolytes, 12/60, 
CPK, and LI A were within normal limits except 
for an alkaline phosphatase of 265 mu /ml: chest 
\-ray showed cardiomegaly, bilateral pleural 
effusions, emphysematous lung fields but no 
masses or infiltrates; and EKG showed left ven- 
tricular hypertrophy and left atrial hypertrophy. 


32 


The West Virginia Medical Journal 


Benign Transudate 

Thoracentesis showed the pleural effusion to 
be a benign transudate. The patient was begun 
on oral digoxin and furosemide with the gradual 
resolution of his congestive heart failure. PPD 
was negative, with positive control skin tests. 
Multiple stools were hemetest negative. Iron 
studies were consistent with an anemia of chronic 
disease. A bone marrow biopsy was non-diagnos- 
tic, but showed no evidence of malignancy. 
Liver-spleen and bone scans were normal. Lltra- 
sound of the abdomen and pelvis showed a 
questionable pelvic mass. CT scans of the chest, 
abdomen and pelvis were normal. 

During bis hospital course, the patient was 
noted to have evening temperature spikes to 
38.5°C. A new. coarse systolic ejection murmur 
was noted at the lower left sternal border. 2-D 
echocardiogram demonstrated aortic regurgita- 
tion and a thickened tricuspid valve, with dense 
and shaggy echos suggestive of vegetations. 
Multiple blood cultures were without growth. The 
patient began to complain of polyarthralgias that 
had been plaguing him for months. Subsequent- 
ly, he developed a migratory polyarthritis involv- 
ing the right knee, right shoulder, left elbow and 
the left first metacarpophalangeal joint. Lrethral. 
rectal and throat cultures were negative for gon- 
orrhea. ANA and rheumatoid factor were nega- 
tive. 

Develops Episcleritis 

The patient developed left episcleritis. One 
morning, he was found to have erythema, 
warmth, tenderness and boggy swelling over the 
bridge of his nose: this resolved within 48 hours. 
Subsequently, the patient developed erythema, 
warmth and swelling over the cartilaginous por- 
tion of his left ear: these findings resolved spon- 
taneously within 24 hours. Given this constella- 
tion of symptoms, a presumptive diagnosis of 
relapsing polychondritis was made. He was be- 
gun on prednisone 10 mg. orally q.i.d. and dis- 
charged from the hospital. He remained asymp- 
tomatic hut suffered Cushingoid side effects. The 
patient’s prednisone was tapered. Subsequently, 
he developed a nasal chondritis and was started 
on dapsone. He has remained asymptomatic. 

Discussion 

Doctor Powers: 

Relapsing polychondritis (RPl is a rare dis- 
ease of unknown etiology which is being recog- 
nized with increasing frequency. Over 200 cases 
have been reported in the world literature to 
date, compared with 10 cases as of 1960. It is 
characterized by episodic, yet generally progres- 


sive, inflammation and degeneration of carti- 
laginous structures throughout the body, and 
recurrent inflammation of special sense organs 
including the eye and ear. 

This syndrome was first described in 1923 
when Jaksch-Wartenhorst 1 reported a 32-year-old 
brewery worker in Prague who initially bad joint 
swelling and pain associated with fever. Later he 
developed in both external ears burning pain and 
swelling which, in three months, receded and 
shrank, leaving deformed pinnae, complete steno- 
sis of both external auditory canals, decreased 
hearing, dizziness and tinnitus. He then de- 
veloped a painless collapse of the middle segment 
of his nose, leaving a saddle deformity. Biopsy 
of the nasal septum showed “no cartilaginous 
matrix and hyperplastic mucosal membranes.” 
During 18 months of followup there was progres- 
sion of a peripheral arthritis with a tendency to 
deformity. Jaksch-Wartenhorst called this dis- 
order polychondropathia. 

In 1935. Altherr 2 and Von Meyenberg 3 separ- 
ately reported the autopsy of a 14-year-old boy 
who had degeneration and destruction of the car- 
tilage of his ears, nose, ribs, joints, larynx and 
tracheobronchial tree. They named the disorder 
chondromalacia. Bean. Drevets and Chapman 4 
described one patient and summarized eight pre- 
vious cases from the literature in 1958. and 
suggested the name of chronic atrophic poly- 
chondritis. Finally. Pearson, Kline and New- 
comer.’’ in 1960. reviewed 10 previously reported 
cases and added four additional ones. They 
suggested the name “relapsing polychondritis.” 
which is now generally accepted. 

RP has been reported in all ages, but seems 
to fit a normal distribution with maximal fre- 
quency in the fourth decade. The average age 
of onset is 44. It is equally divided between the 
sexes. The majority of cases reported have been 
Caucasian: however, the disease has been seen 
in Asians. Hispanics and Blacks. It does not 
demonstrate a familial predisposition; however, 
there is one report of a pregnant woman with 
RP delivering a newborn who was similarly af- 
fected at birth. Another pregnant woman with 
RP reportedly delivered a normal newborn. 

Clinical Presentation 

In 1976. McAdam et al. 6 reported the results 
of a prospective study of 23 patients, and re- 
viewed the world literature to establish the most 
common presenting symptoms of RP. These 
findings were further supported in a report of 
10 cases from the Cleveland Clinic in 1979.' 

Chondritis of the auricles and the arthritis of 
RP are the most common presenting manifesta- 


February. 1983, Vol. 79, No. 2 


33 


tions, accounting for approximately one half of 
cases. The incidence of nasal chondritis, ocular 
inflammation and respiratory tract involvement is 
divided approximately equally, and accounts for 
the majority of remaining presentations. Pa- 
tients presenting with audiovestibular symptoms 
and other miscellaneous syndromes make up the 
remaining small fraction. 

Auricular chrondritis is typically bilateral, and 
presents as the sudden onset of marked redness, 
swelling, warmth and pain, limited to the carti- 
laginous portion of the external ears (helix, anti- 
helix, tragus, and sometimes the external audi- 
tory canal). It is frequently described as having 
a violaceous hue. The ear is very tender to 
touch; the redness may include surrounding 
retroauricular soft tissues and may be accom- 
panied by lymphadenopathy. An important point 
in the differential diagnosis is that the ear lobe, 
lacking cartilage, is always spared. 

The inflammation usually subsides within 5-10 
days but may last as long as four weeks. After a 
single prolonged attack or repeated shorter at- 
tacks, loss of cartilage in the ear results in the 
pinna becoming flabby and droopy; it may even 
flop up and down as the patient walks. These 
external ear changes are frequently referred to as 
“cauliflower ears.” 

Arthritis of RP 

The arthritis of RP, the second most common 
presenting sign, is an inflammatory, oligo- or 
polyarthritis which tends to be asymmetric, and 
may involve the large and small joints of the 
upper extremity, hips, knees, ankles, occasionally 
the spine, and has a predilection for costo- 
chondral junctions, sterno-manubrial, or sterno- 
clavicular joints. It is sero-negative and usually 
non-erosive. At the onset the pattern is often 
migratory, frequently associated with effusions, 
and can mimic closely rheumatoid arthritis or a 
spondylitic variant syndrome. 

Occasionally the arthritis is monoarticular, 
very acute, and suggestive of infectious or 
crystal-induced arthritis. On x-ray there may he 
narrowing of the joint spaces or eburnation (de- 
generative conversion of bone or cartilage into 
a hard ivory-like mass with increased density on 
rotentgenograms as a result of inflammation), 
but usually no destruction. 

RP also can develop in patients with pre- 
existing chronic polyarthritis of various types 
( Reiter’s syndrome, juvenile chronic polyarthri- 
tis, seronegative polyarthritis of the rheumatoid 
type) . 

The nasal chondritis often is of sudden onset, 
with the nose being very painful, red and in- 


flamed. It may be associated with a feeling of 
tremendous fullness in the bridge of the nose 
and surrounding tissues, and occasionally mild 
epistaxis. After repeated bouts of inflammation, 
the nasal cartilage can collapse, forming the 
“saddle nose” deformity, but there have been 
reports of deformity without overt inflammation. 
In one patient the deformity developed over- 
night while asleep. 

Ocular inflammation may involve almost every 
part of the eye and adnexal structures. The most 
common types of eye involvement are conjuncti- 
vitis, episcleritis, iritis and keratitis, with addi- 
tional reports of cataracts, optic neuritis, extra- 
ocular muscle palsy, and exophthalmos. When 
ocular inflammation is the only presenting symp- 
tom, RP is unlikely and the differential diagnosis 
extensive. 

Respiratory Tract Involvement 

Respiratory tract involvement is a relatively 
unusual presenting feature of RP but is note- 
worthy because it represents critical and po- 
tentially lethal organ system involvement. The 
epiglottis, bronchial and thyroid cartilage may 
be involved. The patient may complain of ten- 
derness over the trachea or larynx. Hoarseness, 
at times to the point of aphonia, is a common 
complaint. Some present with dyspnea, char- 
acterized as asthma-like, often with severe in- 
spiratory stridor. Many have an associated 
cough, usually non-productive, rarely with minor 
hemoptysis. 

Eleven of the 14 patients in McAdam’s series 
who presented with respiratory complaints re- 
quired a tracheostomy, and four eventually died 
with respiratory complications. The need for 
tracheostomy may be due to collapse of laryngeal 
or tracheal cartilage, or due to severe glot- 
tic, laryngeal, and subglottic inflammation and 
edema, leading to airway obstruction. Respira- 
tory tract involvement is the main cause of death 
from RP, accounting for almost 50 per cent of 
the cases when the cause is known. 

Unusual Manifestations 

Another less common presenting symptom is 
middle or inner ear involvement manifested 
by sudden or gradual onset of unilateral or bi- 
lateral cochlear and/or vestibular nerve involve- 
ment. The symptoms of nausea, vomiting, verti- 
go, tinnitus and deafness may he transient or 
persistent. Conductive hearing loss due to serous 
otitis as a result of swelling of the eustachian tube 
cartilage may improve somewhat with resolution 
of the swelling and fluid. Sensorineural hearing 
impairment and vestibular dysfunction are pre- 


34 


The West Virginia Medical Journal 


sumed to be due to arteritis of the internal audi- 
tory artery or its vestibular branch. 

Rarely, patients present with diffuse, severe, 
systemic symptoms of fever, anorexia, weight 
loss, arthralgias and myalgias, and represent 
diagnostic dilemmas until other more specific 
signs of RP appear. 

The incidence of specific organ system in- 
volvement in 159 patients also was reported by 
McAdam. 6 The approximate order of occurrence 
was: ll auricular chondritis, 89 per cent: 2) 

polyarthritis or other articular involvement, 81 
per cent; 31 nasal chondritis, 72 per cent: 41 
ocular inflammation. 65 per cent; 51 respiratory- 
tract chondritis, 56 per cent: and 61 audio-vesti- 
bular damage, 46 per cent. Less common are 
cardiovascular involvement, 24 per cent (val- 
vular. nine per centl, and cutaneous lesions, 17 
per cent. A frequent associated finding not in- 
cluded in McAdam’s series is anemia (found in 
10 per cent of Cleveland Clinic series. I 7 

The most common cardiac abnormality is 
aortic insufficiency. Heart failure, as a result, has 
on occasion responded to digoxin and furosamide 
but may require valve replacement. Hemody- 
namically, the most significant cardiovascular 
lesion results from the involvement of the ascend- 
ing aorta and secondary dilatation of the aortic 
annulus leading to aortic regurgitation. The his- 
topathological lesions in the aorta are due to 
medial involvement by the inflammatory process 
consisting of perivascular infiltration, increased 
vascularization and replacement of the elastic 
tissue by collagen tissue (similar to cystic medial 
necrosis ) . 

Aortic Regurgitation 

In the past, it was thought that aortic regurgi- 
tation in RP was secondary to dilatation of the 
aortic ring and not due to valve cusp involve- 
ment. Although thickening of the valve cusps 
was seen in a few instances, it was thought to be 
secondary to mechanical trauma produced by the 
regurgitation. However, in a case reported by 
Sohi et al. in 1981, 8 aortic cusp involvement by 
the inflammatory process, causing hemodynamic 
impairment without clinically and grossly ob- 
vious involvement of the ascending aorta or the 
aortic ring, was the first cardivascular abnor- 
mality. Pertinent to their finding is the fact that 
abnormalities in the composition (amino acids 
and lipids) of the aortic cusps were reported in 
1971 by Alexander et al. 9 Other valvular ab- 
normalities include a few reports of mitral in- 
sufficiency. with one report of a “floppv mitral 
valve” presenting simultaneously with RP. 10 


Additional cardiovascular abnormalities re- 
ported include a 25-per cent incidence of in- 
flammatory vascular disease; aneurysm, throm- 
bosis or vasculitis has occurred in the descending 
or abdominal aorta and in medium-sized arteries, 
subclavian, hepatic, superior mesenteric and 
peripheral arteries. Pericarditis, cardiac isch- 
emia, arrhythmias, etc., have been reported but 
have not acquired significance in terms of fre- 
quency of occurrence. 

Skin lesions also may be a feature of RP, and 
are thought possibly to reflect an underlying 
systemic vasculitis since the majority reported 
are vasculitic in nature. In addition to erythema 
nodosum-like lesions, there have been reports of 
retardation of nail growth, maculopapular erup- 
tions, vesicular lesions and alopecia in one pa- 
tient. 

Diagnostic Criteria 

With the frequencies of organ-system involve- 
ment in mind, McAdam empirically arrived at six 
proposed diagnostic criteria: 6 

1. Recurrent chondritis of both auricles 

2. Non-erosive inflammatory arthritis 

3. Chondritis of nasal cartilages 

4. Inflammation of ocular structures includ- 
ing conjunctivitis, keratitis, scleritis/epi- 
scleritis and or uveitis 

5. Chondritis of the respiratory tract involv- 
ing laryngeal and/or tracheal cartilages 

6. Cochlear and/or vestibular damage mani- 
fest by neurosensory hearing loss, tinnitus, 
and/or vertigo. 

McAdam felt that the diagnosis is based pri- 
marily upon the unique clinical features, and is 
quite certain if three or more criteria are present 
together with histologic confirmation. 

In the 1979 report from the Cleveland Clinic, 
Damiani and Levine proposed an expansion of 
the criteria for diagnosis of RP. They feel that 
a diagnosis of RP can be made when one or more 
of McAdam’s signs are present along with posi- 
tive histologic confirmation; the diagnosis also 
can be made when chondritis is present in two 
or more separate anatomic locations and there is 
response to steroids and/or dapsone. They based 
this proposal on the limited differential diagnosis 
of both the syndrome complex of RP and of three 
of the first five individual signs, namely auricular 
chondritis, nasal chondritis and larvngotracheal- 
hronchial chondritis. Diagnosis of RP based on 
these expanded criteria may lead to early diagno- 
sis and arrest of the disease prior to manifesta- 
tions of its other signs. Early diagnosis and 
treatment should be strongly encouraged in the 


February, 1983, Vol. 79, No. 2 


35 


face of an illness with respiratory or cardio- 
vascular involvement that carries a mortality of 
22 per cent. 

Pathology 

Histologic examination of cartilage from a 
clinically involved site will confirm the under- 
lying chondritis. The cartilage specimen may 
he obtained from the ear, nose or respiratory 
tract — keeping in mind that one does not want 
to produce any additional cosmetic deformities. 
The histologic changes of RP are easily recog- 
nized in florid form. 

First, in a brief review of normal cartilage, the 
two basic components are the cellular (chondro- 
cytes) and intercellular matrix (fibrillar elements 
and ground substance). The ground substance is 
composed of macromolecules called mucopoly- 
saccharides and mucoproteins. The cartilage 
chondrocytes lie imbedded in the inter-cellular 
matrix. The matrix stains basophilic with hema- 
toxylin and eosin and metachromatic with certain 
other stains. 

In relapsing polychondritis, the primary ab- 
normality appears to be in the mucopolysac- 
charide component of the ground substance, re- 
sulting in structural weakness. Light microscopy 
shows loss of basophilic staining of cartilage ma- 
trix, perichondral inflammation, and cartilage 
destruction with replacement by fibrous tissue. 
There is lacunar breakdown and infiltration of 
neutrophils: as inflammation continues, there is 
condensation into irregular whorls of collagen 
with plasma cells and lymphocytic infiltration. 
Chondrocytes dedifferentiate, forming fibro- 
blasts and collagen fibers. Occasionally, small 
sites of cartilage regenerate. There is loss of 
matrix acid mucopolysaccharides, which results 
in the loss of basophilic staining. The primary 
change is loss of matrix acid mucopolysac- 
charides followed by a secondary perichondral 
inflammatory reaction. 

The pathogenesis and etiology of RP are not 
clearly defined. However, the primary abnormal- 
ity appears to lie in the dissolution of the muco- 
polysaccharide component of the ground sub- 
stance by enzymatic proteolysis. 

Experimental Models 

Animal models using papain protease injected 
intravenously into young rabbits can produce 
rapid, diffuse depletion of cartilage matrix and 
collapse of the ears. 11 The same effect has been 
demonstrated with high doses of vitamin A. sug- 
gesting that vitamin A somehow activated pro- 
teolytic enzymes with similar properties to 
papain protease. 12 Rarranco 11 treated rabbits 


with vitamin A and methylprednisolone or with 
vitamin A and dapsone and showed no collapse 
or dissolution of cartilage. Rabbits treated only 
with vitamin A showed collapse of cartilaginous 
components. 

The cause of the proposed activation of pro- 
teolvtic enzymes is not known. A hypersensitivity 
reaction has been suggested by Glynn and Hol- 
borrow, 14 who postulated that a bacteria or virus 
combined with chondroitin sulfate and protein 
in cartilage to form an antigenic substance. This 
would result in auto-antibody formation with 
antigen-antibody complexes activating comple- 
ment. resulting in destruction of cartilage. 

Immunological Abnormalities 

Circulating anticartilage antibodies bave been 
demonstrated by several investigators. An anti- 
cartilage antibody has been shown by direct im- 
munofluorescence in a patient with RP. 1 ’ In a 
1981 report by Ebringer et al. 16 cartilage anti- 
bodies were demonstrated by indirect immuno- 
fluorescence on human fetal cartilage in six of 
nine patients with RP. The highest titers were 
present during the early acute phase of the dis- 
ease. 

Another 1981 report 1 ' demonstrated anti- 
bodies against rat costal cartilage in an RP 
patient’s serum. Fiodart 18 demonstrated circulat- 
ing antibodies to type II collagen during the 
acute phase of RP by indirect immunofluores- 
cence after removal of proteoglycan. 

The significance of these findings remains ob- 
scure as such antibody may be an accompani- 
ment of cartilage destruction and not its cause. 
There also have been reports of cell-mediated im- 
munity to cartilage. 19,20 

Co-existing Diseases 

The co-existence of various rheumatic or 
“auto-immune" diseases noted in RP patients 
suggests a possible immunological mechanism 
underlying RP. The associated disease usually 
precedes the development of RP. McAdam di- 
vided the patients in his series into those with 
“pure” RP (about 75 per cent) and those with 
a co-existing rheumatic or autoimmune disease 
I about 25 per cent ). Rheumatic diseases include 
rheumatoid and juvenile rheumatoid arthritis. 
Sjogren’s syndrome. SLE. systemic sclerosis, 
Reiter’s svndrome or psoriatic arthritis: the auto- 
immune diseases include thvroid disease (goiter. 
Hashimoto’s thyroiditis or hyprothvroidism ) , 
ulcerative colitis, glomerulonephritis, dvsgamma- 
globulinemias and non-caseating granulomas. 

More recent reports include Wegener’s granu- 
lomatosis. periarteritis nodosa, diabetes mellitus 


36 


The West Virginia Medical Journal 


with insulin resistance, vitiligo and antibodies to 
human intrinsic factor and gastric parietal cells. 
There has been a report of RP associated with 
carcinoma of the pancreas, and one report of RP 
preceding Hodgkin s disease by six months. 

Differential Diagnosis 

The differential diagnosis of RP may be ex- 
tensive. If the auricular chondritis is bilateral, 
resolves spontaneously, and is recurrent, the 
differential diagnosis is almost exclusively 
limited to RP. Trauma or infection are other 
possibilities. However, infectious perichondritis 
is usually associated with fever, leukocytosis, 
regional adenopathy, clears with antibiotics, and 
initially may have been associated with trauma, 
mastoid surgery or chronic external otitis. The 
most frequent etiologic agent causing infectious 
perichondritis is Pseudomonas aeruginosa. 

Calcification of cartilaginous structures of the 
ear as found in 40 per cent of patients with RP 
also has been reported in Addison's disease, 
ochronosis, acromegaly, essential hypertension, 
diabetes mellitus, hyperthyroidism and familial 
cold hypersensitivity. 

Nasal chondritis also must be differentiated 
from infectious nasal perichondritis, which usual- 
ly has positive cultures and responds to anti- 
biotics. Nasal collapse resulting in saddle nose 
deformity also may be seen in congenital syphilis 
or Wegener’s granulomatosis. A negative RPR 
and FTA-ABS, and lack of renal involvement, 
pulmonary parenchymal involvement or central 
or peripheral nerve involvement would help to 
rule out these respective diseases. 

Other Similar Diseases 

The articular manfestations of RP may be 
similar to rheumatoid arthritis, but RP-associated 
arthritis usually is not destructive and not asso- 
ciated with rheumatoid nodules or positive rheu- 
matoid factor. 

Reiter’s syndrome resembles polychondritis 
because of the arthritis and eye lesions, but 
differs in that the urethral, dermal, and mucosal 
lesions commonly seen in Reiter’s are not seen 
in RP. 

Several entities have similar ocular inflamma- 
tion, including Reiter’s syndrome, rheumatoid 
arthritis, Still’s disease. Behcet’s disease, entero- 
pathic arthritis. Wegener’s granulomatosis, poly- 
arteritis nodosa. Sjogren s svndrome (kerato- 
conjunctivitis sicca and xerostomia!. Cogan’s 
syndrome I interstitial keratitis and vestibular 
auditory problems such as severe vertigo, tin- 
nitus. ataxia and bilateral sensory neural deaf- 


ness), syphilis, herpes zoster and entities with 
arteriosclerosis. 

The differential diagnosis of laryngeal trach- 
eal bronchial chondritis seen in RP is limited 
to infectious perichondritis, of which there 
could he many causes. 

Laboratory Findings 

The laboratory is only helpful in the diagnosis 
of RP when it serves to exclude other conditions. 
The only consistent findings are an elevated 
erythrocyte sedimentation rate during active dis- 
ease. often with a moderate leukocytosis and 
mild-to-moderate anemia. The anemia is usually 
normochromic and normocytic with low serum 
iron and iron binding capacity ( i.e.. anemia of 
chronic disease I . 

Other laboratory findings tend to be non- 
specific indicators of inflammatory disease. There 
have been a few cases of renal disease (specifical- 
ly glomerulonephritis) associated with RP. but 
there was thought to be another active disease 
process to account for it. There have been re- 
ports of elevated liver function tests, but these 
are usually attributed to passive congestion due 
to heart failure. 

Radiographic, findings includ calcification of 
the ears, nose and trachea: cardiovascular in- 
volvement with cardiomegaly or pulmonary con- 
gestion: or narrowing of joint spaces with ebur- 
nation. But most important is the use of ra- 
diology in evaluating the respiratory system. In 
addition to PA and lateral views of the chest, a 
PA and lateral soft-tissue view of the neck should 
be done to search for narrowing of the cervical 
trachea. Further delineation may be obtained by 
tracheal tomograms with or without radio con- 
trast dye. 

Therapy 

Medical treatment of RP consists primarily of 
corticosteroids, immunosuppressive drugs and 
dapsone ( diaminodiphenylsulfone I . Salicylates, 
phenylbutazone, naprosyn and indomethacin 
have been tried and have been reported to 
he effective in some cases, but are not the 
drugs of choice. A number of cases responding 
to dapsone have been reported in the past six 
years. 1 3,21,22 It is theorized that dapsone func- 
tions in RP by inhibition of lysosomal enzyme 
release and thereby prevents chondrocyte dam- 
age. The range of dosage was 25 mg. to 200 mg. 
per day for one week to two years. The average 
dose was 75 mg. per day for four months. Side 
effects include lethargy, nausea, and hemolvtic 
anemia (especially in G6PD deficiency). Serious 
rashes, agranulocytosis and aplastic anemia have 
been reported. 


February. 1983. Vol. 79. No. 2 


37 


Steroids Drug of Choice 

Steroids are probably still the drug of choice 
in treating RP — especially in the face of a life- 
threatening illness. Corticosteroids have been 
reported to be almost uniformly reliable in abat- 
ing acute periods of activity, and in decreasing 
the frequency and severity of recurrences. They 
frequently are effective in laryngotracheal and 
external ear manifestations and in decreasing the 
sedimentation rate, but not always as helpful in 
the eye manifestations or in treating the sen- 
sorineural hearing loss. 

The starting range is usually 30-60 mg. of 
prednisone per day with larger doses during 
periods of intense disease activity. The average 
daily maintenance dose is 20 mg. per day for 
a period of four months. Alternate-day therapy 
generally has been ineffective. When resolution 
of RP was seen, steroids were tapered, hut there 
have been a number of cases that were never able 
to withdraw completely without an exacerbation. 

In general, it is thought that the response to 
therapy is related to the aggressiveness of the 
disease. A number of patients that have not re- 
sponded to steroids alone have been tried on 
immunosuppressive drugs (azothiaprine, cyclo- 
phosphamide, alkeran, methotrexate, plaquinil, 
nitrogen mustard and 6-mercaptopurine) with 
some success. 

Surgical Treatment Limited 

Surgical treatment of RP is limited. Tra- 
cheostomy may be necessary for respiratory dis- 
tress secondary to tracheal/laryngeal /bronchial 
chondritis. Whether or not to treat the nasal 
collapse cosmetically is debated in the literature, 
with some reports of further deformity resulting. 
One point agreed upon is that no surgery should 
be attempted while the disease is in an active 
phase. Cardiovascular involvement may necessi- 
tate replacement of affected valves, or resection 
of aneurysms. 

Prognosis 

Mortality rates for RP are usually reported to 
be 22 per cent to 30 per cent after four to five 
years of disease. Almost half the deaths are due 
to respiratory involvement, mainly airway col- 
lapse. Other causes of death reported are pneu- 
monia, ruptured aneurysm, vasculitis, cardio- 
vascular (a few post-operative valve replace- 
ment), congestive heart failure, and malignancy. 
A more common prognosis for RP is a low-grade 


and smoldering course over many years with 
good control of symptoms with the use of cortico- 
steroids. 

References 

1. Jaksch-Wortenhorst R: Polvchondropathia. "Wien 

Arch Intern Med 1923; 6:93-100. 

2. Alther RF: Uber einen Fall von systematisierter 

Chondromalacie. Virchows Arch F Pathol Anat 1936; 
297:445-479. 

3. Von Meyerburg R: Ueber chondromalacie. Schweiz 
Med Wochenschr 1936; 17:1239. 

4. Bean WB, Drevets CC, Chapman JS: Chronic 

atrophic polychondritis. Medicine 1958; 37:353. 

5. Pearson CM, Kline HM, Newcomer VD: Relapsing 
polychondritis. N Engl J Med 1960; 263:51. 

6. McAdam LP et al.: Relapsing polychondritis: 

Prospective study of 23 patients and a review of the 
literature. Medicine (Baltimore) 1976; 55(3): 193-215. 

7. Damiani JM, Levine HL: Relapsing polychondritis 
—Report of ten cases. Lanjngoscope 1979; 89:929. 

8. Sohi GS et al.: Aortic cusp involvement causing 
severe aortic regurgitation in a case of relapsing poly- 
chondritis. Cathet Cardiovasc Diagn 1981; 7:79-86. 

9. Alexander CS et al.: Abnormal amino acid and 
lipid composition of aortic valve in relapsing polvchon- 
dritis. Am J Cardiol 1971; 28:337. 

10. Hemry DA et al.: Relapsing polychondritis, a 

“floppv” mitral valve, and migratorv polvtendonitis. 
Ann Intern Med 1972; 77:576-580. 

11. McCluskey RT, Thomas L: The removal of 

cartilage matrix in vivo, by papain. J Exp Med 1958; 
108:371. 

12. Thomas L et al.: Comparison of the effects of 
papain and vitamin A on cartilage. ] Exp Med 1980; 3: 
705. 

13. Barranco V, Mino D, Salamon H: Treatment of 
relapsing polychondritis with dapsone. Arch Dermatol 
1976; 112:1286-1288. 

14. Glynn LE, Holborrow EJ: Conversion of tissue 
polysaccharides to autoantigens by Group-A Beta-Hemo- 
lytic streptococci. Lancet 1952; 2:449-451. 

15. Rodgers JH, Boden G, Jourtellatte CD: Relapsing 
polvchondritis with insulin resistance and antibodies to 
cartilage. Am J Med 1973; 55:243-248. 

16. Ebringer G et al. : Autoantibodies to cartilage and 
type II collagen in relapsing polychondritis and other 
rheumatic diseases. Ann Rheum Dis 1981; 40-473-479. 

17. Meyer O et al.: Relapsing polychondritis— Patho- 
genic role of anti-native collagen type II antibodies. 
I Rheumatol 1981; 8:820-824. 

18. Fiodart JM et al. : Antibodies to type II collagen 
in relapsing polvchondritis. N Engl J Med 1978; 299: 
1203. 

19. Herman JH, Dennis MV: Immunopathologic 

studies in relapsing polvchondritis. J Clin Invest 1973; 
52:549-558. 

20. Rajapakse DA, By waters EG: Cell-mediated im- 
munity to cartilage proteoglycan in relapsing polychron- 
dritis. Clin Exp Immunol 1974; 16(3): 497-502. 

21. Martin J et al.: Relapsing polychondritis treated 
with dapsone. Arch Dermatol 1976; 112:1272. 

22. Ridgway HB et al.: Relapsing polychondritis: 

Unusual neurological findings and therapeutic efficacy of 
dapsone. Arch Dermatol 1979; 115:43. 


38 


The West Virginia Medical Journal 


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OUR LEGISLATIVE PROGRAM 


T)y the time you read this the Legislature will 
he in session. Measures recommended by the 
Steering Committee of the Association's Com- 
mittee on Legislation and approved for sponsor- 
ship by the Council are intended to provide a 
more rational and reasonable system for the trial 
or settlement of medical malpractice actions. 
When enacted, this system should help reduce 
the cost of liability insurance and thereby de- 
crease the cost of medical care for all. 

A brief summary of measures our Association 
has introduced include those to: (1) limit the 
statute of limitations to a more reasonable time 
frame: (2) introduce collateral sources of pay- 
ments for damages: (3) determine reasonable 
and equitable contingency fees for attorneys: (4) 
eliminate demands for outlandish sums of money 
in claims: (5) establish reasonable limits to 
awards for non-economic loss; (6) establish de- 
grees of liability proportionate to the degree of 
responsibility if more than one party is involved: 
(7 ) provide for periodic payment of damages so 
the award goes to the injured party: and ( 8) pro- 
vide appropriate copies of records to be available 
to patients. 

This legislation will not be a shield to protect 
MDs or to prohibit lawsuits for negligence. Any- 
one who has an injury from negligence is entitled 
to just, reasonable, and equitable compensation 
for it. The key words, though, are “just, reason- 
able. and equitable." A medical misadventure is 
not a reason to reap windfall profits for the pa- 
tient or the attorney, any more than having an 
operation should he a reason for the patient to 


submit bills to three different insurance com- 
panies to profit from the illness. 

The intent of our legislative program is to put 
a damper on unreasonable and exhorbitant 
awards, disproportionate to the injuries sus- 
tained. to plaintiffs and attorneys alike, not to 
deny reasonable, just and equitable compensa- 
tion to those who have truly suffered injury. We 
must pass this measure on to our legislators, our 
patients and the public. If we do not, in the end 
all of us will pay the inflated cost. 

In discussing these and other issues with sev- 
eral members of the Legislature, I have found 
them receptive and willing to listen. They ap- 
preciate knowing the facts, for these issues are 
clouded by emotion, and emotional issues are 
hard to deal with rationally and logically. The 
ball is in our court now. If you. the Membership, 
are not interested enough to initiate a discussion, 
make a phone call, or write a letter, we cannot 
expect the members of the Legislature to be 
interested enough to make the hard choices re- 
quired of these emotion-laden issues. They want 
and need the information we can provide in 
order to make some hard decisions. It is the duty 
and responsibility of each one of us to do all 
be or she can to provide this information. We 
must not abdicate this responsibility. 








Harry Shannon. M. D.. President 
West Virginia State Medical Association 


40 


Thf, West Virginia Medical Journal 


The Vest Virginia riedical Journal 

Editorials 

The Publication Committee is not responsible for the authenticity of opinion or statements made by authors or 
in communications submitted to this Journal for publication. The author shall be held entirely responsible. 
Editorials printed in The Journal do not necessarily reflect the official position of the West Virginia State 
Medical Association. 


Among 50 recommendations given the Gover- 
nor and the Legislature by the state's Health 
Cost Containment Task Force was one calling 
for creation of another such study group in the 
general area of malpractice insurance. 

In summary, the recommendation called for 
a task force, with members knowledgeable about 
insurance, law and medicine. 
PRIORITY GOOF "to specifically consider in- 
surance and tort law reforms 
for the resolution of complaints of medical and 
hospital malpractice."’ 

But when the cost containment task force was 
putting its final report together, and ranking in 
order of priority various recommendations under 
the so-called "hospital medical" group, it placed 
the malpractice problem issue 11th on a list 
of 12. 

State Attorney General Chauncey Browning, 
who chaired the health care cost study unit 
created by Governor Rockefeller on September 
28, 1981, explained that the task force — which 
held 13 monthly meetings over a period of more 
than a year — simply did not have time to study 
this particular issue. 

To some, that wasn't a very adequate answer. 
Browning himself earlier had commented that 
there was no group in West Virginia “that knows 
more about the health care cost situation than 
this Task Force. That being the case, how did 
the growing professional liability problem fall 
down the crack? The force’s final report indi- 
cated that it didn t — at least, not entirely. 

“It was brought to the attention of the Task 
Force that malpractice insurance for hospitals 
and physicians is an expenditure that increases 
the costs of health care." the report noted. “Due 
to their specialty, some physicians pay more 
than $20,000 per year for malpractice insurance." 
The report continued: 

“In addition, it is said that many laboratory 
tests and x-rays are routinely ordered merely for 
malpractice prevention rather than because there 
is any reasonable need for the services." 


Then came the observation that “this Task 
Force has considered many areas, and has not 
had the time to concentrate upon the malpractice 
area to the extent necessary to develop a recom- 
mendation that would propose a solution to the 
problem.” 

Accordingly, “This Task Force recommends 
the appointment of another group to specifically 
consider the malpractice problem." 

A lack of time by the health care cost study 
group to consider this particular issue now is the 
proverbial water over the dam. But how a Task 
Force that considered itself as most knowledge- 
able about health care costs could rank the pro- 
fessional liability problem No. 11 on a list of 12 
items must remain somewhat of a mystery. 

Maybe, in all of its work, the group didn t 
have time to read a newspaper every now and 
then. That’s really all that would have been 
necessary to get some inkling of the scope of the 
difficulty. 


We will be a long time getting over missing 
Clark Sleeth. Much will be said and written 
about our gentle contemporary. Especially will 
those who matured under his wise direction in 
the School of Medicine try to express his worth 
to them, and he unable to 
CLARK KENDALL put their thoughts into 
SLEETH, 1913-1982 words that mean what they 
feel about Clark. Even 
more so do we, his equals in time, find it hard 
to say what our hearts are shouting inside as we 
keep missing him. There is a great urge to pay 
him tribute by way of the written word. And so 
we surrender to it. knowing full well the effort 
will not say it adequately. 

When we first knew him as assistant in Doctor 
Van Liere's physiology department in the old 
medical school — we of the last great class of 
84 souls to be admitted to the old school — 
his always friendly mien and his concern were 
like soothing unguent to our eroding egos as we 
struggled to stay afloat in the first year’s un- 


February, 1983, Vol. 79, No. 2 


41 



certain seas. And it’s hard to separate that Clark 
from the one we have known in recent years, for 
he has never changed from the always dignified 
but cheerful and witty, friendly and encouraging 
helper of all who came to him for support. And 
he has shared those benefits with countless 
patients as he has practiced the art of healing 
with the same intensity which was part of his 
every endeavor. 

We will leave to others the telling of his 
scientific, scholastic and administrative talents 
which so notably served the need of our Uni- 
versity Medical Center. For example, the De- 
partment of Family Practice will pay him tribute 
for its existence, and for being perhaps the most 
effective among the host of determined and hard- 
working family doctors who for years had been 
pushing for its founding. But those are not the 
things we miss about Clark, for the torch of these 
responsibilities passed smoothly from his weary- 
ing hands to other capable ones. 

So it’s pretty hard to pinpoint the why about 
our missing Clark. We have wonderful Nellie 
to call on and talk to, and everything she is has 
a lot to do with our missing him. It’s just hard 
to say. But we will take a long time to get over 
missing Clark Sleeth. And maybe we never will. 
— JNJ 


As indicated in The Journal's January issue, 
several so-called tort reform bills are a part of 
the State Medical Association’s 1983 legislative 
program. In that light, the fol- 
GOLD RUSH lowing comments by Charles D. 

Hollis, Jr., M. D., President of the 
Medical Association of Georgia, not only are 
interesting, but call new attention to some key 
components of the liability insurance dilemma. 
Here’s Doctor Hollis: 

“The alarming escalation of frequency and 
severity of malpractice claims is not just a 
problem facing hospitals and physicians. The 
staggering sums of money awarded must ulti- 
mately come from patients, thus becoming a 
significant factor in the increase in all medical 
costs. But the awarded monies are only the tip 
of the iceberg. Otherwise unnecessary tests, 
x-rays, and hospitalizations ordered as a pro- 
tection against medical malpractice claims in- 
crease utilization and constitute as much as an 
estimated 30 per cent of the total health care 
expenditures. This is 30 per cent of the $300 
billion spent on health care services annually 
in this country. From a personal perspective, 
I believe that these estimates are realistic. 


“Thus, in the professional liability fiasco, we 
are dealing with a social problem, not just with 
a medical economics problem. It is of such 
magnitude that we are compelled to take legis- 
lative action to offer relief to the public. We 
must look to our friends in the Legislature to 
find meaningful and constitutionally sound tort 
reform laws. 

“It won’t be easy. The plaintiff bar has to 
consider the hundreds of millions of dollars in 
contingency fees and will thus oppose any effort 
to improve the professional liability insurance 
climate. But, I believe it is possible — if we 
teach the business community and our patients 
what is involved. A well planned and coordi- 
nated effort will be necessary. Indiana has 
implemented model tort reform legislation which 
has withstood challenges in the courts. As a 
consequence, Indiana physicians and patients 
have been spared the apprehension, frustration, 
and expenses faced by physicians, hospitals, and 
their patients in most states. 

“The public welfare is involved. As concerned 
physicians, we cannot afford to allow the gold 
rush by the plaintiff bar to block efforts now 
to effectuate meaningful tort reform.” 



Violation of Ethics 

On April 15, 1982, in Indianapolis, Indiana, an in- 
nocent, defenseless newborn human being was killed 
(murdered) by starvation and dehydration with the 
sanction of the courts. Infant Doe was not only refused 
surgical care to correct an esophageal-tracheal fistula, 
but had fluids and food withheld until the baby died six 
days later. Why was this allowed to happen? Because 
he was something less than “normal.” He had Down’s 
Syndrome. 

Where is the blame to be put for such a blatant act? 
Surely the parents must be blamed for being unwilling to 
accept their responsibility. Certainly the courts must ac- 
cept blame. To me, however, the most blame must lie 
with the doctor who, by doing what he did, no matter 
at whose insistence, violated every principle of medical 
ethics. A doctor’s responsibility is always to attempt to 
cure, not to kill. What a precedent this could set- 
accepting killing as an acceptable mode of treatment. 

I have seen this case reported in medical literature but 
I have not seen it condemned in medical literature. Has 
the abortion (killing) ethic so inured us that such actions 
are now acceptable? Even if the courts declare such 
conduct to be legal, should the medical profession blindly 
follow? I hope and pray not! 

Clarence H. Boso, M. D. 

Huntington, WV 


42 


The West Virginia Medical Journal 


GENERAL NEWS 


Program For Annual Meeting 
Begins To Take Shape 


Two general scientific programs featuring 
symposia on sexually transmitted and cardiovas- 
cular diseases will feature the West Virginia 
State Medical Association’s 116th Annual Meet- 
ing August 25-27. 



The convention at the Greenbrier in White 
Sulphur Springs will 
get under way with 
the usual Council 
meeting on Thursday 
morning, August 25, 
and the first House of 
Delegates session that 
afternoon. 

Frank J. Jirka, Jr., 
M. D., Chicago area 
urologist who will take 
office in June as the 
American Medical As- 
David z. Morgan, m. d. sociation President, 
has been invited to 
address the first House meeting. 


The initial general scientific session at 9:45 
A.M. on Friday, August 26, will be preceded 
by the traditional opening exercises. A keynote 
speaker for that program will be announced 
later. 


David Z. Morgan, M. D., of Morgantown, the 
Annual Meeting Program Committee Chairman, 
said the symposium on sexually transmitted 
diseases Friday morning will include papers on 
these individual topics: 

Syphilis and gonococcal infections: non-luetic, 
non-gonococcal venereal diseases; transmissible 
diseases of the gay patient, and sexual mores 
in the 1980s. 


The Program Committee will announce later 
speakers for this symposium, as well as for the 
cardiovascular disease program on Saturday 
morning, August 27, and upcoming issues of 
The Journal will provide such details. 

Saturday morning topics will include new 
developments in the management of cardiac 
arrythmias; an update relative to cardiovascular 


surgery, and the management of congestive heart 
failure. 

Specialty Meetings Planned 

In addition to the general sessions, the Annual 
Meeting agenda will include breakfast, luncheon 
and other programs arranged by specialty 
societies and sections, many of which also will 
provide scientific discussions. 

The specialty group meetings will be held in 
large measure on Friday, with a few to be set 
for Saturday morning, preceding the second 
general session, and at noon. 

The House of Delegates will hold its second 
and final session on Saturday afternoon, at which 
time Carl R. Adkins, M. D., of Oak Hill will be 
installed as the Association’s 1983-84 President 
to succeed Harry Shannon, M. D., of Parkers- 
burg. 

Continuing a practice of many years, the 
Auxiliary to the State Medical Association, with 
Mrs. Richard S. Kerr of Morgantown the cur- 
rent President, will hold its meeting in con- 
junction with that of the Association. 

Others serving with Doctor Morgan on the 
1983 Program Committee are Doctor Adkins; 
Jean P. Cavender, M. D., Charleston; Michael 
J. Lewis, M. D., St. Marys; Kenneth Scher, 
M. D., Huntington, and Roland J. Weisser, Jr., 
M. D., Morgantown. 

Reservation forms provided by the Greenbrier 
were mailed to Association members with Execu- 
tive Secretary Charles R. Lewis , annual bulletin 
early in January. 

The membership is urged to give the matter 
of reservations its earliest possible attention. If 
forms for some reason did not reach physicians, 
others may be obtained from the Association’s 
headquarters office, P. 0. Box 1031, Charleston 
25324. 


Congress’ Lame Duck Session 
Leaves AMA-FTC Deadlock 

The American Medical Association and 
Federal Trade Commission fought to a standstill 
in the lame duck session of Congress, with the 
final version of the continuing resolution funding 
various agencies of government until early this 


February, 1983, Vol. 79, No. 2 


43 


year omitting any mention of the FTC’s having, 
or not having, jurisdiction over the professions. 

That leaves the situation where it was two 
years ago, hut AMA lobbyists did succeed in 
removing the language of the Rudman Amend- 
ment. which was adopted by a vote of 15-14 by 
the Senate Appropriations Committee. 

The Rudman Amendment prevailed when the 
Chairman, Senator Mark Hatfield, Oregon Re- 
publican, was called upon to break a 14-14 tie. 

The Senate tabled, or killed, by a 59-37 vote, 
the proposal that would have prevented the FTC 
from investigating or taking action against 
medicine or other state-regulated professions. 

At 6 A. M. the morning of December 16, the 
House adopted the language of the Rudman 
Amendment ( similar to the Broyhill Amend- 
ment ) giving FTC jurisdiction over the pro- 
fessions. 

AMA lobbyists went to work to prevent the 
adoption of this language, which would have 
established FTC’s jurisdiction. The result of that 
effort was the expunging of the Rudman langu- 
age from the continuing resolution, leaving the 
long controversy right where it was. 

The AMA bill, to remove any doubt of FTC 
jurisdiction over the state-regulated professions. 


Review A Book 


The following books have been received by the 
Headquarters Office of the State Medical Associa- 
tion. Medical readers interested in reviewing any 
of these volumes should address their requests to 
Editor, The West Virginia Medical Journal. Post 
Office Box 1031, Charleston 25324. We shall be 
Tiappy to send the books to you, and you may 
keep them for your personal libraries after sub- 
mitting to The Journal a review for publication. 

Current Obstetric and Gynecologic Diagnosis 
and Treatment , 4th Edition, edited by Ralph 
C. Benson. M. D. 1.038 pages. Price $25. 
Lange Medical Publications, Los Altos, Cali- 
fornia 94022. 1982. 

Basic and Clinical Pharmacology, by Bertram 
G. Katzung. M. D.. Ph.D. 815 pages. Price 
$23.50. Lange Medical Publications, Los Altos. 
California 94022. 1982. 

Nine Months’ Reading: A Medical Guide for 
Pregnant IV omen , 3rd Edition, by Robert E. 
Hall. M. D. 178 pages. Price $13.95. Double- 
day & Company, Inc.. 245 Park Avenue, New 
York. New 5 ork 10167. 1983. 


will have to be introduced in the new Congress, 
which convened in January. 

In the meantime, the regulatory agency’s 
authority over medicine is now the law of only 
the Second Circuit, not the law of the land. 

The 4-4 U. S. Supreme Court decision, which 
gave no opinion and thus set no precedent, 
merely let stand the decision in that circuit. 


Family Physicians’ Meeting 
Scheduled In April 

“Physician, Heal Thyself" will be the theme 
for the opening session of the 31st annual 
scientific assembly of the West \ irginia Chapter. 
American Academy of Family Physicians, to be 
held April 15-17. 


Gordon H. Deckert, M. D. Donald L. Cooper, M. D. 

The meeting site will be the Lakeview Inn 
and Country Club in Morgantown, with the first 
session to begin Friday morning, April 15. 

Some 15 physicians and others will make up 
the faculty for the scientific sessions which, in 
addition to the Friday morning session, will be 
held Friday afternoon. Saturday morning and 
afternoon, and Sunday morning. 

The opening session will be presented in two 
parts, “Physician. Know Thyself" and “Physi- 
cian, Linderstand Thyself." by Gordon H. 
Deckert. M. D., and Jane Chew Deckert. B. D., 
M. S. Doctor Deckert is Professor and Head. 
Department of Psychiatry and Behavioral 
Sciences, F niversity of Oklahoma College of 
Medicine, Oklahoma City. Presentation tech- 
niques will include dramatization and structured 
group exercises. 

The Assembly program is acceptable for 18 
and one-half Prescribed hours by the AAFP, 
and is approved for the same number of hours 




44 


Thf. West Virginia Medical Journal 


/ii 

Donald S. Robinson, M. D 

in Category 1 of the Physician’s Recognition 
Award of the American Medical Association. 

Family physicians will be welcomed to the 
scientific assembly by Dr. Robert D. Hess of 
Clarksburg, President. Opening remarks will be 
made by Drs. Arlo P. Brooks, Jr., of Parkers- 
burg, President Elect and Program Chairman, 
and Harry Shannon, also of Parkersburg. Presi- 
dent of the State Medical Association. 

Other Speakers 

Other speakers and their topics will be: 
Friday Afternoon: “What Is Your Fitness?’ - 

— Donald L. Cooper, M. D., Director. Student 
Health Center. Oklahoma State University; 
"Dealing with the Impaired Physician " — Perry 
R. Ayers, M. D., Clinical Professor, Department 
of Preventative Medicine, Harding Hospital. 
V orthington. Ohio: and “Office Management 
of Family Physicians' Practices” — David C. 
Scroggins, M.B.A., C.P.B.C., Clayton L. Scrog- 
gins Associates, Inc., Cincinnati. 

Saturday Morning: “Diagnosis and Treat- 
ment of Sleep Disorders : “Respiratory Im- 

pairment in Sleep — Clinical Manifestations, 
Diagnosis and Current Treatment Approaches” 
Helmut S. Schmidt, M. D., Director, Sleep 
Disorders Evaluation Center. Ohio State Uni- 
versity, Department of Psychiatry, Columbus; 
"Now I Lay Me Down to Sleep . . . Insomnia” 
Thomas Roth. Ph.D., Director, Sleep Dis- 
orders and Research Center, Henry Ford Hos- 
pital, Detroit; and “Pharmacology and Ther- 
apeutics of Hypnotic Drugs” — Donald S. 
Robinson. M. D.. Chairman and Professor. De- 
partment of Pharmacology, and Professor of 
Medicine, Marshall University. 

Saturday Afternoon: “Peptic Ulcer Disease” 

— George J. Brodmerkel, Jr., M. D., Head. 
Division of Gastroenterology, Department of 
Medicine, Allegheny General Hospital, Pitts- 
burgh; “Treatment of Low Back Pain" — 


Gerald R. Gehringer. M. D., Professor and Head, 
Department of Family Medicine, Louisiana 
State L niversity, New Orleans; and national 
President. AAFP; “Hypertension Treatment for 
Family Physicians” — Joseph M. Pitone, D.O., 
Assistant Professor of Medicine, Department of 
Nephrology and Hypertension. University of 
Medicine and Dentistry of New Jersey, New 
Jersey School of Osteopathic Medicine; and 
Head. Subsection. Department of Nephrology 
and Hypertension. John F. Kennedy Memorial 
Hospital, Stratford (New Jersey) Division: and 
“A Recent Update on Beta Blockers” — Wayne 
A. Border. M. D., Chief of Nephrology, Uni- 
versity of Utah, Salt Lake City. 

Headaches in Children 

Sunday Morning: “Recent Advances in Treat- 
ment of Headaches in Children" — Arnold D. 
Rothner. M. D.. Chief, Section of Child 
Neurology, The Cleveland Clinic Foundation; 
“The Use of Thrombolytic Therapy in Venous 
Thromboembolic Disease" — Ronald N. Rubin. 
M. D., Director, Oncology L T nit, and Assistant 
Professor of Medicine, Temple University Hos- 
pital: “New Concepts in Rheumatology" — 
Steven Abramson, M. D., Assistant Professor of 
.Medicine. New V ork University Medical Center. 
New V ork City: and “Senile Dementia” — James 
T. Hartford, M. D., Associate Professor and 
Chief. Geriatric Psychiatry, University of 
Cincinnati. 

Additional meeting details are scheduled to 
appear in the March issue of The Journal. Mean- 
while. registration and other information may 
be obtained by calling I 304 ) 776-1178. 


David J. Fine Named To Fill 
WVU Hospital Post 

David J. Line, Senior Associate Director of 
the University of Nebraska Hospital and Clinic 
at Omaha, has been appointed Administrator of 
West Virginia University Hospital. 

John L. Jones, M. D., WVU Vice-President 
for Health Sciences, said Fine assumed his new 
duties in January on a part-time basis and would 
be full-time within three months. 

He succeeds Eugene L. Staples who resigned 
to become director of the University of Kansas 
Medical Center hospital last June. Associate 
Administrator Bernard G. Westfall has been serv- 
ing in the interim. 

Fine. 32. was born in Flushing, New York, and 
is a graduate of Tufts University and the Uni- 
versity of Minnesota. 





February, 1983, Vol. 79, No. 2 


45 


Continuing Education 
Activities 


Here are the continuing medical education 
activities listed primarily by the West Virginia 
University School of Medicine for part of 
1983, as compiled by Dr. Robert L. Smith, 
Assistant Dean for Continuing Education, and 
J. Zeb Wright, Ph. D., Coordinator, Con- 
tinuing Education, Department of Community 
Medicine, Charleston Division. The schedule is 
presented as a convenience for physicians in plan- 
ning their continuing education program. (Other 
national, state and district medical meetings are 
listed in the Medical Meetings Department of 
The Journal. ) 

The program is tentative and subject to 
change. It should be noted that weekly confer- 
ences also are held on the Morgantown, Charles- 
ton and Wheeling campuses. Further information 
about these may be obtained from: Division of 
Continuing Education. WVU Medical Center, 
3110 MacCorkle Avenue, S. E., Charleston 
25304; Office of Continuing Medical Education. 
WVU Medical Center, Morgantown 26506: or 
Office of Continuing Medical Education, Wheel- 
ing Division, WVU School of Medicine, Ohio 
Valley Medical Center. 2000 Eoff Street. Wheel- 
ing 26003. 

Eeb. 6-9, Snowshoe, Surgical Conference 

March 18, Charleston, 10th Annual Newborn 
Day 

March 25-26, Morgantown, Infection Control 
Workshop 

March 28-29, White Sulphur Springs, Sym- 
posium on Tumors for the Orthopedic 
Surgeon 

April 28, Wheeling, Balance Disorders 

April 29, Charleston, Research Day 

April 29-30, Morgantown, Orthopedic Reunion 
Days 

May 7, Charleston, Outpatient Infectious 
Diseases 

May 12-13, Morgantown, Health Officers Con- 
ference 


Regularly Scheduled Continuing 
Education Outreach Programs from 
WVU Medical Center/ 
Charleston Division 

Buckhannon , St. Josephs Hospital, first-floor 
cafeteria, 3rd Thursday, 7-9 P. M. — Feb. 

( winter break ) 

March 17, “Thyroid Dysfunction: Diagnosis 
and Management,” Richard Kleinmann, M. D. 
April 21, “Prenatal Disorders and Congenital 
Anomalies,” R. Stephen S. Amato, M. D. 

Cabin Creek, Cabin Creek Medical Center, 
Dawes, 2nd Wednesday, 8-10 A. M. — Feb. 
9, “Evaluation and Treatment of Burns,” 
Augusto Portillo, M. D. 

March 9, “Overall Outpatient Management of 
Renal Dysfunctions,” Mary Lou Lewis, M. D. 

Gassaway, Braxton Co. Memorial Hospital, 1st 
Wednesday, 7-9 P. M. — Feb. 2, “Yes, Vir- 
ginia, There Are Venereal Diseases in Rural 
Practices,” Patrick Robinson, M. D. 

March 2. “Enteral Alimentation." Brittain 
McJ unkin, M. D. 

April 6, “Clinical Intervention in Drug & 
Alcohol Abuse,” Thomas Haymond, M. D. 

Madison, 2nd floor. Lick Creek Social Services 
Bldg., 2nd Tuesday, 7-9 P. M. — Feb. (winter 
break ) . 

March 8, “Drug & Alcohol Abuse: Interven- 
tion Strategies,” Thomas Haymond, M. D. 

Oak Hill, Oak Hill High School ( Oyler Exit, N 
19) 4th Tuesday, 7-9 P. M. — Feb. (winter 
break ) . 

March 22, “End-Stage Renal Disease,'" Mary 
Lou Lewis, M. D. 

April 26. “Adolescent Sexuality: Recognizing 
& Treating Pathological Behavior," T. 0. 
Dickey, M. D. 

IVelch, Stevens Clinic Hospital. 3rd Wednesday, 
12 Noon-2 P. M. — Feb. (winter break). 

March 16, “Protocols for Treating Poisonous 
Snake Bites,” David 0. Wright, M. D. 

W hitesville, Raleigh-Boone Medical Center, 4th 
Wednesday, 11 A. M.-l P. M. — Feb. (winter 
break ) . 

March 23, “Hypertension Update: Diagnosis 
& Management,” Stephen Grubb. M. D. 

April 27, “Obesity: Emotional Factors in 

Compliance,” John Linton, Ph.D. 


46 


The West Virginia Medical Journal 



Williamson, Appalachian Power Auditorium. 1st 

Thursday, 6:30-8:30 P. M. — Feb. (winter 

break ) . 

March 3, “Suicide Intervention,” Martin 

Kommor. M. D. 

New Dean Said ‘Outstanding’ 

For Era Of Change 

A West Virginia University search committee 
considered nearly 70 persons before recommend- 
ing Dr. Richard A. DeVaul of Texas for the post 
of Dean of the WVU School of Medicine. 

This was noted by Dr. John E. Jones, WVU 
Vice-President for Health Sciences, who called 

Doctor DeVaul “a man 
of outstanding cre- 
dentials and accom- 
plishment, and note- 
worthy scholarship.” 
Doctor Jones also com- 
mented, “We believe 
he will provide the 
kind of leadership 
needed in the era of 
substantial change 
which the WVU School 
of Medicine is enter- 
mg. 

Doctor DeVaul, 
whose appointment was announced in December, 
will take over the WVU post this spring. He 
currently is Associate Dean for Student and 
Curriculum Affairs at the University of Texas 
Medical School at Houston. 

Specializing in psychiatry. Doctor DeVaul, 42, 
received his medical degree from the University 
of Rochester, and did his psychiatric residency 
at Johns Hopkins University. 

A native of Ames, Iowa, Doctor DeVaul re- 
ceived his bachelor of science degree from Iowa 
State University, graduating with the highest 
scholastic honors. During his medical education 
at Rochester, he was awarded a summer fellow- 
ship in cardiology at Stanford University. 

Navy Flight Surgeon 

After a year of internal medicine residency at 
University Hospitals in Iowa City, he was a 
Navy flight surgeon for three years with the 
Presidential helicopter squadron at Quantico, 
Virginia, before entering psychiatry residency. 

Doctor DeVaul joined the psychiatry faculty 
at the University of Texas Medical School in 
Houston in 1974, also serving as Director of 
Liaison Psychiatry. He also has appointments in 


the Departments of Medicine and Family Prac- 
tice, continuing that work after becoming As- 
sociate Dean in 1979. 

Since 1975 he has been coordinator for the 
Health Science Center’s Pain Clinic, and last 
year served as Chairman of the Center’s Educa- 
tion Task Force. 

Doctor DeVaul was Steering Committee Chair- 
man for the University of Texas System Health 
Professional Schools in 1977-78. He has been 
an examiner for the American Board of 
Psychiatry and Neurology, and consultant to a 
review group of the National Institute of Mental 
Health. 

Research, Clinical Interests 

Since 1975 he has authored or co-authored 61 
publications, abstracts or other presentations. 
His research and clinical interests cover a wide 
range, from chronic pain syndrome and the 
grieving process to emotional factors in illness 
and drug dependency. 

He is co-author of “Psychiatry’s Role in 
Medical Education," a chapter in the new book. 
Psychiatry in Crisis. 

Doctor Jones was Dean of the Medical School 
from 1974 until his appointment last April as 
Vice-President. Dr. Robert H. Waldman, Chair- 
man of the Department of Medicine, has been 
serving as Interim Dean. 

The search committee for the new Dean was 
headed by Dr. Alvin L. Watne at WVU. 


AM A Panel To Evaluate 
New Procedures 

The American Medical Association’s role in 
technology assessment has expanded with the ap- 
pointment of 500 physicians to serve on the new 
Diagnostic and Therapeutic Technology Assess- 
ment I DATTA ) project. Selected panelists will 
answer queries from business, industry, govern- 
ment agencies, and the medical profession on the 
benefits, risks, and cost-effectiveness of new pro- 
cedures. With the guidance of the Council on 
Scientific Affairs, the DATTA panelists will 
examine medical technologies that are passing 
from experimental or investigational use to ac- 
cepted forms of treatment. DATTA will define, 
where possible, indications for their use. 

No fewer than 20 participating physicians will 
be asked to contribute their expertise in develop- 
ing responses to each outside inquiry. The 
panelists' opinions will be tabulated, and a con- 
sensus will be issued as to whether a procedure 



Richard A. DeVaul, M. D. 


February, 1983, Vol. 79, No. 2 


47 



should be considered as established, investiga- 
tional. unacceptable, or indeterminate. When a 
consensus cannot be reached, the council may 
call for a special study, conference, or report. 

In the future, DATTA panelists will be 
selected by the council from nominations 
solicited from all segments of the AMA. 


HHS Starts Fraud Hot Line 
For Its Programs 

A nationwide toll-free hot line has been 
established by the U. S. Department of Health 
and Human Services to receive information 
about fraud, waste, and abuse in any of the De- 
partment's 350 programs, including Medicare 
and Medicaid. The number is (800) 368-5779. 
Operators in the Inspector General's office will 
answer. 

As a pilot for the national hot line, HHS set 
up a local Washington number two years ago. 
More than 5,900 federal workers and taxpayers 
have used the local number to report fraud and 
abuse. About 10 per cent of the complaints 
resulted in remedial action. In one case, the 
administrator of a federal program and two con- 
tractors went to jail for overcharging Medicare 
by $567,000. 


Physicians’ Image Both 
Positive, Negative 

Physicians' public image remains excellent in 
some areas, according to a public opinion survey 
conducted by an independent research firm for 
the American Medical Association. In 1.504 
telephone interviews with randomly-selected 
respondents, the majority said that physicians 
are accessible in an emergency (81 per cent), 
explain things well to their patients (55 per 
cent), take a genuine interest in their patients 
(68 per cent), are up-to-date on the latest ad- 
vances in medicine (71 per cent), and genu- 
inely are dedicated to helping people (80 per 
cent ). Some 65 per cent disagreed with a state- 
ment that physicians act as if they are better 
than other people. 

I lie image was tarnished, however, in other 
areas. People are beginning to lose faith in 
physicians, said 62 per cent of the respondents. 
They agreed with statements that physicians are 
too interested in making money I 60 per cent), 
and disagreed with statements that physicians’ 
fees usually are reasonable (57 per cent dis- 
agreed), and that physicians spend enough time 
with their patients (52 per cent disagreed). 


Medical Meetings 


Feb. 8-12 — Am. College of Emergency Physicians, 
Surgery/Trauma, Detroit. 

Feb. 11-13 — Biomedical Topics in Psychiatry (Medi- 
cal College of VA), Hot Springs, VA. 

Feb. 18-20 — Regional CME Meeting, Am. College of 
Physicians, Alexandria, VA. 

March 4-6 — Am. Medical Student Assoc., Cleevland. 

March 5-12, Canadian Am. Medical Dental Assoc., 
Vail, CO. 

March 10-15 — Am. Academy of Orthopedic Sur- 
geons, Anaheim, CA. 

March 20-24 — Am. College of Cardiology, New Or- 
leans. 

April 7-8 — WV Chapter, Am. Academy of Pediatrics, 
Beckley. 

April 15-17 — WV Chapter, AAFP, Morgantown. 

April 16-21 — Am. Academy of Pediatrics, Phila- 
delphia. 

April 17-21 — Am. Urological Assoc., Las Vegas. 

April 17-22 — Operative Treatment of Fractures & 
Nonunions (Johns Hopkins University), Hot 
Springs, VA. 

April 18-22 — Am. Roentgen Ray Society. Atlanta. 

April 22-24 — Medical Staff Leadership Seminar 
(Southern Medical Assoc.), Hilton Head, SC. 

April 24-28 — Am. Assoc, of Neurological Surgeons, 
Washington. D. C. 

May 4-7 — WV Chapter, Am. College of Surgeons, 
White Sulphur Springs. 

May 6-8 — Southern Medical Assoc. Regional Post- 
graduate Conference, Lexington. KY. 

May 8-12 — Am. College of Obstetricians & Gyne- 
cologists, Atlanta. 

May 13-14 — Topics in Cardiovascular Diseases (Am. 
Heart Assoc.), Baltimore. 

June 19-23 — Annual Meeting of AMA House, Chi- 
cago. 

Aug. 25-27 — 116th Annual Meeting, W. Va. State 
Medical Assn.. White Sulphur Springs. 

Sept. 29-Oct. 2 — Am. Society of Internal Medicine, 
San Francisco. 

Oct. 16-21 — Am. College of Surgeons, Atlanta. 

Nov. 6-9 — Scientific Assembly, Southern Medical 
Assoc.. Baltimore. 


48 


Thf. West Virginia Medical Journal 




SAAB HAS 
MORE CARGO SPACE 
THAN BMW, 
AUDI, AND VOLVO. 

COMBINED. 


Flip down the back seat of a Saab and you get 
56.5 cubic feet of cargo space (53 in a 4-door 
model). 

Now compare that to the 16 cubic feet you 
get in an Audi 5000. The 13. 9 you get in a Volvo 
GLT Turbo. Even the posh 22.5 you get in a 
BMW 733i (and see how much good posh does 
you when you’re packing up the summer house). 

Of course, you can’t flip down the back seat of 
any of these cars. So they might say Saab has an 
unfair advantage. 

We couldn’t agree more. 


The most intelligent car ever built. 


WVU Medical Center 
—News— 


Compiled from material furnished by the Medical Center 
News Service, Morgantown, W. Va. 


Nephrology Chief Receives 
National Kidney Award 

Frederick C. Whittier, Jr., M. D., Professor 
of Medicine and Chief, Nephrology Section, has 
been named a recipient of a Distinguished Service 
Award by the National Kidney Foundation. He 
received the award for his concern and dedica- 
tion on behalf of the Foundation and its pro- 
grams. 

A member of the Foundation for 11 years, 
Doctor Whittier has been active on both the 
Affiliate and National levels. On the Affiliate 
level, he served as President of the National 
Kidney Foundation of Kansas and Western 
Missouri and as Chairman of its Medical Ad- 
visory Board. Nationally, he has served as 
Chairman of the National Medical Advisory 
Board, the Sub-committee on Organ Donation 
and as a member of tbe Foundation’s Executive 
Committee. 

Doctor Whittier also served as Program Chair- 
man of the Foundation’s Clinical Dialysis and 
Transplant Forum for two years beginning in 
1978. 

A member of the Editorial Board of tbe 
Foundation’s official journal, tbe American 
Journal of Kidney Diseases, Doctor Whittier also 
is a member of numerous other organizations 
including the American Society of Nephrology, 
the American Society of Artificial Organs, the 
American Association of Tissue Banks, the 
Transplantation Society and the American 
Society of Transplant Physicians. 


Emergency Helipad At WVU 
Hospital Donated 

WVU Hospital will soon have its first paved, 
lighted and close-in landing pad for helicopters, 
a gift of James A. LeRosa, Jr., Clarksburg coal 
operator and businessman. 

The landing site, used in bringing critically ill 
or injured patients to tbe Medical Center, will be 



located about 30 yards from the emergency de- 
partment entrance. A grassy site about 150 
yards from the emergency entrance was used 
previously. 

“In the past we had to use an ambulance to 
transport patients from the landing site to the 
hospital.” said John S. Veach, M. D., Assistant 
Professor of Surgery and Medical Director of the 
Emergency Department. “Now we’ll have a 
direct paved walkway, and can bring patients 
in on wheeled stretchers.” 

Coordinator for the gift was Alvin L. Watne, 
M. D., Chairman of Surgery. He said the gift 
was made in kind, with construction materials 
and work crews and equipment being provided 
by LaRosa’s firm. Lights donated by Sharpe 
Electric Co. of Weston will be installed later. 

The project involves major earth moving and 
transporting some 3,000 cubic yards, or 130 
truckloads, of fill, paving a 40-foot diameter 
landing pad with six inches of concrete over six 
inches of crushed rock, and a 10-foot walkway 
30 feet long to the Emergency Department drive. 
The fill is about eight feet deep at the outer edge, 
sloping to nearly ground level adjacent to the 
driveway. 

“This will mean a marked improvement in 
our ability to work with critically ill patients 
being transported by helicopter,” said Dr. Walter 
H. Moran, Chief of Emergency Services. “The 
pad will be lighted in accord with FAA regula- 
tions, and is in an area cleared of obstructions.” 


Doctor Wible Heads State 
Pediatrics Chapter 

Kenneth L. Wible, M. I)., of the pediatrics 
faculty is the new Chairman of the West Virginia 
Chapter of the American Academy of Pediatrics. 

Doctor Wible, Associate Professor, took office 
for a tbree-year term at the Academy’s recent 
national convention in New York City. 

A graduate of Juniata College and the Medi- 
cal School of Thomas Jefferson University in 
Philadelphia. Doctor Wible joined tbe WVU 
faculty in 1969. He is Director of the Medical 
Center’s pediatric group practice. 


x 


The West Virginia Medical Journal 


“The rehabilitation of head-injured patients 
is an intensive, sophisticated procedure” 

says Jose Amayo, M.D., Hamiarville Rehabilitation Center 


“From morning ’til night, head-injured 
patients are involved in rehabilita- 
tion,” says Dr. Amayo, director of 
Harmarville’s head injury program. 

“Our program has four primary 
elements: cognitive retraining to 
improve memory, attention span and 
communication skills; physical restor- 
ation services to help patients relearn 
walking and caring for themselves; 
a vocational program to prepare 
patients for employment, further 
training or education; and programs 
to help patients deal with routine 
social and recreational activities. 

“We also use a computer and 
new diagnostic tools, like die evoked 
potential system. This sophisticated 
equipment permits us to measure 
hearing, vision and sensation.” 


Other special 
Harmamille programs: 

• Pain program to help patients 
control and live with pain, 
particularly neck- and back- 
injured persons. 

• Neuro-spinal program for the 
rehabilitation of quadriplegics 
and paraplegics. 

• Claims Assessment for Rehabil- 
itation Evaluation and Services 
(CARES) for returning injured 
workers to maximum level of 
function and employment. 


For more information on Harmar- 
ville, its head injury program and 
admission procedures, call Dr. 
Amayo, 781-5700. 



Harmarville Rehabilitation Center, P.O. Box 11460, Guys Run Road, Pittsburgh, PA 15238 


Third-Party News, Views 
and Program Concerns 



Caution In Prospective Payment 
System Advised By AMA 

The American Medical Association has cau- 
tioned the Congress to proceed slowly in imple- 
menting a system for prospective payment for 
hospital services. 

Joseph F. Boyle, M. D., Chairman of the AMA 
Board of Trustees, recently told a congressional 
committee that the AMA supported developing 
and exploring payment systems for institutions 
based on “predetermined rates or other payment 
systems that create incentive for facilities to be 
more cost-conscious.” 

He warned, however, that “it would be in- 
appropriate to institute a radical change in the 
Medicare and Medicaid hospital reimbursement 
system without assurances that quality care will 
be maintained.” 

Doctor Boyle also cautioned against imple- 
menting any full-scale prospective payment 
system “without experimentation and until on- 
going projects have been analyzed to determine 
their effects on costs and quality.” 

Effects in Human Terms 

Testifying before the Health Subcommittee 
of the House Commerce Committee, the AMA 
official urged Congress to “consider not only 
how much these programs are designed to save 
in terms of dollars but also what effects they 
will have in human terms and upon the quality 
of care that will be available to the American 
people.” 

In his testimony, Doctor Boyle emphasized 
that “decisions made in the near future con- 
cerning how hospitals and other providers are 
reimbursed will have long-range implications on 
access to and the quality of care for years to 
come.” 

Hospitals, through their boards, admini- 
strators, and medical staffs, are likely to respond 
to changes in the reimbursement system to try 
to maintain access and quality care, he said. If 
hospitals find they are being under-reimbursed. 

xii 


he continued, likely actions will be shifting costs 
to other payers, deferring such spending as 
maintenance ( often leading to higher long-term 
costs), and postponing or eliminating necessary 
modernization and technological improvements, 
depriving patients of the highest quality of care. 

“In extreme cases, hospitals providing es- 
sential care could be forced to close.” he warned. 

Further Demonstrations Urged 

Current data are not adequate to confirm 
that prospective payment is an appropriate 
nationwide reimbursement system. Doctor Boyle 
continued. “We strongly urge that further 
demonstrations go forward before any attempt 
is made to radically alter the manner in which 
payment is made for hospital care.” 

Lacking, he said, is detailed information about 
what long-term changes would occur in hospitals 
under a prospective payment system. “What 
do we do if the ‘incentives’ change behavior in 
a way that cuts costs but also forces elimination 
of needed services and activities?,” he asked. 
“Considerations such as these are best answered 
through demonstration projects prior to the 
nationwide implementation of a new Medicare 
reimbursement system." 

“It is important to determine not only 
whether there are short-term savings that may 
be generated by a prospective payment system, 
but also whether the hospitals will continue to 
be able to provide quality care.” 

Access Could Be Hindered 

The physician pointed out that while prospec- 
tive payment systems could be tailored to achieve 
cost savings, “the question of side effects . . . 
must be considered.” He quoted a General Ac- 
counting Office report earlier this year warning 
that “there is a point when a reduction in 
reimbursement could adversely affect access to 
and or quality of care for beneficiaries. Also, 
if the prospective reimbursement does not apply 
to all payers, a facility can have an incentive 
to shift costs to non-covered payers." 


The West Virginia Medical Journal 





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Obituaries 


KENNETH E. BLUNDON, M. D. 

Dr. Kenneth E. Blundon of Eugene, Oregon, 
formerly of Charleston, died on November 17, 
1982, at his home. He was 64. 

Doctor Blundon retired as a urologist in 1978, 
having been Chief of Urology at Sacred Heart 
General Hospital in Eugene from 1968 to 1972. 

A native of Washington, D. C.; he practiced 
in Charleston from 1953 until moving to Eugene 
in 1962. 

He was a former member of the Kanawha 
Medical Society and the West Virginia State 
Medical Association. 

Survivors include the widow; two sons, 
Kenneth J. Blundon of Springfield, Oregon; 
Parke E. Blundon of Seattle; a daughter, Elaine 
Price of Grants Pass, Oregon, and a sister, Mrs. 
Martha Halluin of Gambrills, Maryland. 

* # # 

A. C. WOOFTER, M. I). 

Dr. A. C. Woofter, Parkersburg internist from 
1934 until 1980, died on December 16, 1982, 
in a Parkersburg hospital. He was 75. 

Doctor Woofter was a Past President and 
honorary member of the Camden-Clark Memorial 
Hospital staff, and was the first Chairman of the 
hospital's Department of Internal Medicine. He 
also was a member of the staff at St. Joseph’s 
Hospital. 

A native of Weston, Doctor Woofter was 
graduated from West Virginia Wesleyan College, 
and received his M. D. degree in 1933 from 
the University of Michigan. 

He interned at Mercy Hospital in Toledo, 
Ohio. 

He was a Diplomate of the American Board 
of Internal Medicine, and a Fellow of the Ameri- 
can College of Physicians and the American 
College of Cardiology. 

Doctor Woofter was an honorary member and 
Past President of the Parkersburg Academy of 
Medicine, and an honorary member of tbe West 
Virginia State Medical Association and American 
Medical Association. 

He also was an honorary member and Past 
President of the West Virginia Heart Associa- 
tion and the Wood County Heart Association, 
and was a member of the International Society 
of Internal Medicine. 

Doctor Woofter served as a major in the U. S. 
Public Health Service from 1942 to 1946. 


Surviving are two sons. Andrew C. Woofter. 
Jr., and Joseph C. Woofter, M. D., both of 
Parkersburg. 

* * * 


SIEGFRIED WERTHAMMER. M. D. 

Dr. Siegfried Werthammer, former Chairman 
of the Marshall Llniversity School of Medicine 
Pathology Department, died on January 2 in 
Sarasota, Florida. He was 71. 

A native of Vienna, Austria, Doctor Wert- 
hammer received his M. D. degree in 1935 from 
the University of Vienna. 

He came to Huntington in 1939 as Director 
of Pathology at the former Huntington Memorial 
Hospital. 

Doctor Werthammer was Chief Pathologist 
and Director of Laboratories at St. Mary’s Hos- 
pital in Huntington from 1942 to 1961, and was 
Chief of Pathology at Cabell-Huntington Hos- 
pital from 1955 to 1979. 

He developed the pathology residency training 
program at Cabell-Huntington for the MU 
School of Medicine. 

Doctor Werthammer was a former member of 
the Cabell County Medical Society and the West 
Virginia State Medical Association. 

Surviving are the widow; a daughter, Ann 
Roth of Huntington, and a son. Dr. Joseph 


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xiv 


The West Virginia Medical Journal 



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P.O. Box 3186, Charleston, WV 25332 
Telephone: 1-304-347-0708 


County Societies 


MONONGALIA 

The Monongalia County Medical Society met 
on December 7. The principal speaker was 
Edward Pastilong, Assistant Athletic Director at 
West Virginia University. His guests were 
Darryl Talley, Mark Raugh and Todd Campbell, 
all WVU varsity football players. 

Dr. Richard A. DeVaul, newly appointed 
Dean of the WVU School of Medicine, was 
introduced to the Society. 

The Society approved a donation of $5,000 
to the Morgantown Hospice, Inc. This sum will 
be matched by the Hazel Ruby Foundation. 

A moment of silence was observed in the 
memory of the late Drs. Clark K. Sleeth and 
Bernard Zimmermann. — Robert L. Murphy, 
Executive Secretary. 

# * * 

TYGART’S VALLEY 

The Tvgart’s Valley Medical Society met on 
November 18 at the Elkins Motor Lodge in 
Elkins. 


Dr. Harry Shannon of Parkersburg, President 
of the State Medical Association, addressed the 
Society on a variety of subjects concerning the 
Association and the medical profession. 

Dr. Carl H. Cather, Jr., of Morgantown was 
the scientific speaker. His topic was “Ear, Nose 
and Throat Allergy.’' — Michael M. Stump, 
M. D., Secretary. 


EQUIPMENT WANTED 

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and exam room equipment. Also, instru- 
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Send responses to P. 0. Box 1645, Beckley, 
WV 25801. 


Over 40 Practice Opportunities 
In rural West Virginia 

CONTACT 

Health Professions Recruitment Project 
West Virginia Department of Health 
1800 Washington Street, East 
Charleston, West Virginia 25305 

Phone: 348-0575 


OFFICERS OF COMPONENT SOCIETIES 


Society 

President 

Secretary 


Meetings 

Boone 

Sriramloo Kesari 

Madison 

Manuel T. Uy 

Madison 

2nd Tues. 

Brooke 

Rogelio L. Velarde 

Follansbee 

W. T. Booher, Jr. 

Wellsburg 


Cabell 

Charles E Turner 

Huntington 

S. Kenneth Wolfe 

Huntington 

2nd Thurs. 

Central West Virginia 

Joseph B. Reed 

Buckhannon 

Greenbrier Almond 

Buckhannon 

As Sched. 

Eastern Panhandle 

John S. Palkot 

Martinsburg 

Francisco D. Sabado, Jr. 

Martinsburg 

2nd Wed. 

Fayette 

Amor H. Ramirez 

Montgomery 

Serafino S. Maducdoc, Jr. 

Montgomery 

1st Wed. 

Greenbrier Valley 

Stephen L. Sebert 

Lewisburg 

Charles E. Weinstein 

Ronceverte 

2nd Wed. 

Hancock 

Reynaldo B Vista 

Weirton 

Timothy A Brown 

Weirton 

3rd Tues. 

Harrison 

Gaspar Z. Barcinas 

Bridgeport 

James E. Bland 

Clarksburg 

1st Thurs. 

Jefferson 

Jules F. Langlet 

Charles Town 

William S Miller 

Ranson 

1st Wed. 

Kanawha 

Donald E. Farmer 

Charleston 

Robert B Point 

Charleston 

2nd Tues. 

Logan 

Herbert D. Stern 

Logan 

Tivitmahaisoon Chanchai 

Logan 

2nd Wed. 

Marion 

P. Kent Thrush 

Fairmont 

Mack 1. McClain 

Fairmont 

Last Tues. 

Marshall 

Carlos C. Jimenez 

Glen Dale 

Jose J. Ventosa 

Glen Dale 

1st Tues. 

Mason 

Mel P Simon 

Point Pleasant 

Richard L. Slack 

Point Pleasant 

4th Tues. 

McDowell 

Haresh Khatri 

Welch 

John S. Cook 

Welch 

2nd Wed. 

Mercer 

Mario Cardenas 

Princeton 

David F Bell, Jr 

Bluefield 

3rd Mon. 

Mingo 

Edward B. Headley 

Delbarton 

Nikhanth Purohit 

Williamson 

2nd Wed. 

Monongalia 

N. LeRoy Lapp 

Morgantown 

Robert Bettinger 

Morgantown 

1st Tues. 

Ohio 

Thomas L. Thomas 

Wheeling 

James C. Durig 

Wheeling 

4th Tues. 

Parkersburg Academy 

Billie M. Atkinson 

Parkersburg 

John E. Beane North Parkersburg 

1st Thurs. 

Potomac Valley 

Suratkal V. Shenoy 

Keyser 

Larry C Rogers 

Keyser 

2nd Wed. 

Preston 

Gary W. Lawrence 

Kingwood 

C. Y. Moser 

Kingwood 

4th Thurs. 

Raleigh 

Jose L. Oyco 

Beckley 

William C. Covey, Sr. 

Beckley 

3rd Thurs. 

Summers 

Jack D. Woodrum 

Hinton 

Chandra P Sharma 

Hinton 

3rd Mon. 

Tygart's Valley 

Karl Myers, Jr. 

Philippi 

Halberto G. Cruz 

Philippi 

3rd Thurs. 

Western 

Herminio L. Gamponia 

Spencer 

AM H. Morad 

Ripley 

Bi-Monthly 

Wetzel 

Donald A. Blum 

New Martinsville 

K. M. Chengappa New Martinsville 

Monthly 

Wyoming 

Frank J. Zsoldos 

Mullens 

George F. Fordham 

Mullens. 

Quarterly 


xviii The West Virginia Medical Journal 



The West Virginia Hectical Journal 

Vol. 79, No. 3 March, 1983 

Acquired Factor VIII Inhibitor* 
(A Case Report) 


SUSAN IRBY, M. D. 

Pittsburgh , Pennsylvania 

JOHN S. ROGERS II, M. D. 

Associate Professor of Medicine, Section of Hema- 
tology/Oncology, Department of Medicine, West Vir- 
ginia University Medical Center, Morgantown 

DOUGLAS C. WOLF, M. D. 

Cleveland, Ohio 


An elderly woman presenting with gross 
hematuria and later gastrointestinal bleeding was 
found to have an acquired inhibitor to clotting 
Factor VIII. Transfusions with large amounts 
of Factor VIII concentrate transiently corrected 
the prolonged partial thromboplastin time 
( PTT) and the depressed Factor VIII clotting 
level. 

Additional laboratory abnormalities included 
mild prolongations of both prothrombin time 
I PT ) and thrombin time ( TT ) which were not 
corrected in vitro by the addition of equal 
volumes of normal plasma or in vivo by Factor 
VIII infusion. 

A diagnostic approach to a patient with a 
suspected clotting inhibitor is discussed. The 
present case is compared to previous reported 
cases of acquired Factor VIII clotting inhibitors. 

A cquired Factor VIII inhibitors most com- 
monly occur in hemophilia patients receiv- 
ing Factor VIII infusions but have been de- 
scribed in non-hemophiliacs. 1,2,3 ' 4 We report a 
patient with an acquired Factor VIII clotting 

“This paper was written while Doctors Irby and Wolf 
were residents in medicine at West Virginia University 
Medical Center, Morgantown. 


inhibitor. The present case is compared to 
previous reported cases. The need for appropri- 
ate diagnosis and treatment is discussed. 

Case Presentation 

A 72-year-old black female was admitted for 
evaluation of gross hematuria of three weeks’ 
duration. The patient denied previous episodes 
of hemorrhage, and had undergone both an 
appendectomy and full-mouth dental extraction 
in the past without significant bleeding. She 
had been taking aspirin for two years for 
degenerative arthritic pain, and more recently 
eimetidine I Tagamet I for epigastric discomfort. 
Her medical history further revealed a poorly 
substantiated diagnosis of multiple myeloma 
made one year previously. She had been 
treated with lumbar radiation and daily oral 
dexamethasone (Decadron). 

During her recent hospital course, cystoscopv 
and retrograde pyelography revealed bleeding 
from both ureteral openings, and hydrone- 
phrosis of the right kidney. Table 1 shows the 
initial coagulation studies. The partial throm- 
boplastin time ( PTT I was markedly elevated, 
and the prothrombin time (PT) and thrombin 
time (TT) were mildly prolonged. The platelet 
count and Ivy bleeding time were normal. The 
plasma fibrinogen and fibrin split products 
I FSP ) were both increased. 

Further laboratory evaluation revealed the 
presence of a Factor \ III clotting inhibitor of 
moderate titer. The PTT was repeated on serial 
dilutions of the patient’s plasma with normal 
plasma. One would expect a clotting factor de- 


March, 1983, Vol. 79, No. 3 


49 


ficiency to be corrected by an equal volume of 
normal plasma, that is, a 1:1 dilution. In our 
case, complete correction of the prolonged PTT 
did not occur until the 1:8 dilution. Incubation 
of the mixture at 37 C for one hour enhanced 
the inhibition, i.e., the PTT of the mixture pro- 
longed further with time. The patient’s clotting 
Factor VIII level (F VIII-C) was decreased to 
0.14 units /ml (normal range 0.56-1.55 units/ 
ml ). Levels of Factors II, V, IX and X were all 
normal. Quantitation of the Factor VIII inhibitor 
activity by the method described by Kasper 5 
revealed a moderate titer of 18 Bethesda units. 

Reason Not Clear 

While the prolonged PTT is explained by the 
Factor VIII inhibitor, the reason for the ab- 
normalities in the PT and TT is not clear. The 
mixing of equal volumes of patient and control 
plasma (1:1 dilution ) produced incomplete cor- 
rection of the PT and TT. Transfusions of large 
amounts of Factor VIII concentrates corrected 
the prolonged PTT and the depressed Factor 
VIII level. Table 2 shows normalization of the 
Factor VIII level with marked shortening of the 
PTT one hour post-infusion. The mild ab- 
normalities of the PT and TT were not affected. 

The evaluation of our patient for underlying 
disease was inconclusive. An abnormal pap 
smear was suggestive of malignancy. Following 
infusion of a large dose of Factor VIII concen- 
trate, cervical biopsy plus dilatation and curet- 
tage were performed without significant bleeding. 


TABLE 1 

Initial Lab Studies 



Patient 

Normal 


PTT 

72.0 sec. 

31.4 sec. 


PT 

13.5 sec. 

10.6 sec. 


TT 

43.4 sec. 

23.7 sec. 


Platelets 

375,000/cu mm 

140-440, 000/cu 

mm 

Fibrinogen 

530 mg/dl 

200-400 mg/dl 


FSP 

>40 ug/ml 

<10 ug/ml 


Ivy BT 

4 min. 

1-6 min. 



TABLE 2 


Effects of Infusion of 10,000 Units of 
Factor VIII Concentrate 



Normal 

Pre Post 

F VIII 

1.00 ± .21 u/ml 

0.14 u/ml 1.09 

u/ml 

PTT 

33.4 sec. 

62.8 sec. 41.4 

sec. 

PT 

11.1 sec. 

13.8 sec. 13.2 

sec. 

TT 

23.4 sec. 

34.4 sec. 41.2 

sec. 


The cervical biopsy showed epithelial dysplasia. 
The endocervical and endometrial scrapings re- 
vealed atypical cells suggestive of malignancy. 
The presence of multiple myeloma was not con- 
firmed by bone marrow biopsy or by serum and 
urinary electrophoresis. 

While hospitalized, the patient developed an 
upper gastrointestinal bleed. Endoscopy exami- 
nation revealed duodenitis. The patient was 
continued on the Factor VIII concentrate in- 
fusions on a daily basis with control of major 
bleeding symptoms. Two weeks prior to dis- 
charge she was begun on Prednisone 20 mg. 
every six hours. The requirement for Factor 
XIII infusions gradually decreased, and she was 
discharged on prednisone. 

The patient was seen two weeks later as an 
out-patient. Both the hematuria and gastroin- 
testinal bleeding had resolved. At that time, the 
inhibitor titer had decreased to five Bethesda 
units. The PTT had decreased to 38.8 sec., and 
the Factor VIII level was 0.46 u ml. One month 
later, the patient was admitted to another hos- 
pital where she died secondary to gastrointestinal 
bleeding. An autopsy was denied. 

Discussion 

The in vitro and in vivo studies in our patient 
are consistent with an acquired F VIII inhibitor 
of moderate titer. The reason for the mild pro- 
longation of the PT and TT in our patient is 
uncertain. The incomplete correction of the 
TT in vitro by equal volumes of control plasma 
and in vivo by Factor VIII concentrate infusion 
suggests a second site of inhibition, perhaps due 
to the increased fibrin split products. Fibrin 
split products are known to have an anti- 
thrombin effect. The presence of elevated FSPs 
with a normal platelet count and increased 
plasma fibrinogen raises the possibility of 
compensated disseminated intravascular coagu- 
lation ( DIC I or primary fibrinolysis. 

Acquired Factor VIII inhibitors occur most 
commonly in hemophiliacs, but have been as- 
sociated with a variety of disease states. In a 
1975 review article, Shapiro 4 cited patients with 
long-standing asthma, pemphigus, psoriasis, and 
non-specific dermatitis who developed inhibitors 
to Factor VIII. Patients with connective tissue 
disease such as systemic lupus erathematosis, 
rheumatoid arthritis and temporal arteritis 
occasionally have inhibitors to Factor VIII. 
Anticoagulants also have been found in patients 
in the postpartum period. 2 in patients with 
dysproteinemias, 6 and have been associated with 


50 


The West Virginia Medical Journal 


reactions to penicillin, nitrofurazone. phenyl- 
butazone and sulfa. 3 

Non-hemophiliac children have been reported 
to develop Factor VIII inhibitors after viral in- 
fections. 1 Others have noted a connection be- 
tween inhibitors and occult malignancy, and in 
elderly patients who are otherwise healthy. 2,3 
Factor VIII inhibitors have been described in 
patients with cancer, including Hodgkin’s 
disease, prostate cancer, myelofibrosis and can- 
cer of the cervix. 

The Factor VIII inhibitor has been character- 
ized as an auto-antibody mainly of the IgG 
class. 2 Subtyping reveals the majority to be of 
the IgG4 subclass. The light chain is frequently 
restricted, with Kappa chains occurring most 
commonly in hemophiliacs with inhibitors. The 
reaction with Factor VIII follows first order 
kinetics and is progressive. The reaction re- 
quires several hours and can be dissociated. The 
progressive nature of the reaction was apparent 
in the correction studies in our patient. The 
inhibitor may disappear after several weeks or 
may persist for years. 

Why the Anticoagulant? 

The cause of the circulating Factor VIII anti- 
coagulant in our patient is unclear. The diagnosis 
of multiple myeloma was not confirmed. In 
regard to medication, the patient had been 
taking dexamethasone and eimetidine prior to 
the onset of hematuria. Neither drug is known 
to be associated with Factor VIII inhibitor for- 
mation. The possibility exists that the patient 
had endometrial or cervical carcinoma. 

While the incidence of acquired Factor VIII 
inhibitor is low, it may be the cause of significant 
morbidity and mortality. Suggested treatment 
includes infusion of large doses of Factor 
concentrate. If the inhibitor is of low titer, as 
in the present case, such an approach may con- 
trol bleeding. Plasma exchange transfusions 
may be employed in an attempt to decrease the 
amount of circulating inhibitor; however, the 
effects are transient, as the majority of the IgG 
antibody is extravascular. 8 

Immunosuppression with cyclophosphamide 
or prednisone requires several weeks to months 
to affect the inhibitor level, and is frequently 
ineffective. Prothrombin complex concentrates 


contain Factors II. VII. IX and X. Factors IX 
and X may appear in the activated form. Clini- 
cal studies involving hemophilia patients with 
Factor VIII inhibitors suggest that prothrombin 
complex concentrates may partially bypass the 
need for Factor VIII in thrombin formation and 
improve hemostasis. 8 Newer preparations spe- 
cifically designed to contain activated vitamin 
K-dependent clotting factors are now com- 
mercially available. 9 

Acquired clotting Factor VIII inhibitors can 
be life-threatening, but with proper diagnosis 
and hematological support, bleeding can often 
be stabilized. Control of an associated under- 
lying disease may lead to the disappearance of 
the inhibitor. On occasion, spontaneous remis- 
sions or responses to immunosuppression occurs. 
Therefore, it is important to be able to recognize 
the nature of the bleeding disorder and. if an 
inhibitor is found, to search for its cause, while 
appropriate hematological support is given. 

Acknowledgements 

The authors wish to thank Frances S. Jencks 
for technical assistance and Annorah L. Cale for 
secretarial assistance. 

References 

1. Brodeur GM, ONeil PJ, Williams JA: Acquired 
inhibitors of coagulation in non-hemophiliac children. 
1 Pediatr 1981; 96:439-441. 

2. Poon M, Wince AC, Ratnoff OD, Bernier GM: 
Heterogeneity of human circulating anticoagulants 
against antihemophiliac factor (Factor VIII). Blood 1975; 
46:409-416. 

3. Shapiro S, Hultin M: Acquired inhibitors to the 
blood coagulation factors. Semin Thromb Hemostas 
1974; 1(4): 336-385. 

4. Shapiro S: Characterization of Factor VIII anti- 
bodies. Ann \Y Acad Sci 1975; 240:350-361. 

5. Kasper CA: More uniform measurement of Factor 
VIII inhibitors. Thromb Diathos Haemorrh (Stuttg) 1975; 
34:869-872. 

6. Lackner H: Hemostatic abnormalities with dyspro- 
teinemias. Semin Hematol 1973; 10:125-133. 

7. Schleider MA, Nachman RL, Jaffe EA, Coleman 
M : A clinical studv of the lupus anticoagulant. Blood 
1976; 48:499-509. 

8. Penner JA: Efficacy of activated prothrombin com- 
plexes. Scand ] Haematol [Suppl] 1980; 24:146-151. 

9. Abildgard CF, Penner JA, Watson-William EJ : 
Anti-inhibitor coagulant complex (Autoplex) for treatment 
of Factor VIII inhibitor in hemophilia. Blood 1980; 
56:978-984. 


March, 1983, Vol. 79, No. 3 


51 


Early Attenuation Of Toxic Shock Syndrome 
With Intravenous Nafcillin Sodium 


THOMAS T. SMIRNIOTOPOULOS, M. D. 
Department of Emergency Medicine, 

Jefferson Memorial Hospital, Ranson, West Virginia 

VETTIVELU MAHESWARAN, M. D. 

Department of Obstetrics and Gynecology, 

Jefferson Memorial Hospital 


A 22-year-old woman presented with an acute 
febrile illness suggestive of Toxic Shock syn- 
drome. Early treatment with intravenous nafcil- 
lin sodium and aggressive fluid replacement 
attenuated the majority of signs and symptoms. 
Subsequent recovery of coagulase-positive 
staphylococcus aureus from vaginal cultures con- 
firmed the diagnosis. It is suggested that more 
liberal criteria be used to define Toxic Shock 
syndrome to allow earlier recognition and treat- 
ment and thus prevent morbidity. 

'"poxic SHOCK syndrome (TSS) is an acute 
illness characterized by the abrupt onset 
of fever, headache, gastrointestinal symptoms 
and a characteristic erythematous rash which 
invariably progresses to desquamation one to 
two weeks later. 1 As the name implies, profound 
hypotension with consequent oliguria are promi- 
nent features, often requiring intensive intra- 
venous therapy and occasionally dialysis. 7,8 

TSS is now recognized as a unique disease 
occurring almost exclusively in women who are 
using tampons. 2 4 Epidemiologic studies suggest 
that the causative agent is a toxinogenic strain 
of coagulase-positive staphylococcus aureus 
(CPS) which has been recovered from the 
vaginas of the majority of patients. 5,6 

We report the following case of TSS in which 
the early administration of intravenous nafcillin 
sodium ( Nafcil I markedly reduced the severity 
of the illness. The accepted criteria for establish- 
ing the diagnosis of TSS were not initially met 
by our patient, thus necessitating a high index 
of suspicion in order to initiate appropriate 
therapy. 

Case Report 

A 22-year-old, white, female college student 
reported to the emergency room at Jefferson 
Memorial Hospital on March 11, 1982. following 
a syncopal episode. The patient had been ex- 
periencing headache, fever, nausea and vomit- 
ing, and diarrhea for 12 hours. She had seen 
the school nurse on two occasions and was given 


acetaminophen ( Tylenol l for the fever and 
kaolin-pectin I Kaopectate ) for the diarrhea. 
The patient had an episode of orthostatic 
syncope in her dormitory and was brought to 
the emergency room. 

On further questioning the patient noted that 
she had been on her menstrual period for the 
past week and that she was using tampons 
( Playtex Super-absorbent). She also recalled 
having had an infected hair follicle on her right 
thigh prior to the onset of her period. The 
patient denied any prior history of menstrual- 
related illness, and was on no medications other 
than those mentioned. 

On physical examination the patient appeared 
ill but was alert and well-oriented. Temperature 
was 100 6 degrees Farenheit; pulse, 88; blood 
pressure. 102/70 supine and 98/70 sitting, and 
respiratory rate, 20. The skin was warm and 
dry. There was a diffuse erythroderma of the 
face and chest suggestive of a mild sunburn. 
The conjunctiva were inflamed but without 
exudate, and the pharynx was normal-appearing. 
There was no adenopathy. The lungs were clear 
to auscultation and the heart sounds were 
normal. The abdomen was soft with active 
bowel sounds and no tenderness or guarding. 

A pelvic examination was performed, the 
tampon removed and vaginal cultures obtained. 
There was a scant white discharge with no bleed- 
ing from the cervical os. The uterus and adnexa 
were normal. A thorough search for the reported 
infected hair follicle was negative. 

Laboratory studies obtained on admission in- 
cluded urinalysis with s.g. 1.020. pH 5.0, 34- 
glucose, 24~ acetone and six to eight white blood 
cells per high-power field. Hemoglobin was 
13.6 g d 1 with hematocrit of 40.3 per cent. The 
white blood cell count was 10.400 with 92 per 
cent neutrophils, five per cent bands and three 
per cent lymphocytes. Blood urea nitrogen was 
14 mg/dl, serum glucose, 120 mg/dl, and 
amylase, 45 mg/dl. Serum electrolytes were as 
follows: sodium, 143; potassium, 3.8; chloride, 
100, and bicarbonate, 25(mEq/L). Gram stain 
of the vaginal fluid revealed mixed flora and 
few polymorphonuclear cells. Cultures of blood, 
urine and pharynx were taken during the initial 
examination. 


52 


The West Virginia Medical Journal 


Hospital Course 

The presumptive diagnosis of Toxic Shock 
syndrome was made and the patient admitted to 
the intensive care unit. She was treated with 
nafcillin sodium one gram intravenously every 
four hours, as well as rapid infusion of five- 
per cent dextrose in normal saline. During the 
first eight hours, total urine output was only 
325 ml. 

The patient became afebrile on the second 
hospital day with urine output returning to 
normal. At this time she had developed edema 
of the face, hands and feet, and was complaining 
of paresthesias of the hands, but was otherwise 
markedly improved. 

Cultures of blood and urine were negative on 
the third hospital day, and the pharyngeal 
culture was negative for group A streptococcus. 
Vaginal cultures obtained on admission yielded 
a heavy growth of coagulase-positive staphylo- 
coccus aureus. The patient was placed on oral 
cloxacillin I Tegopen l and was discharged on 
the morning of the fourth hospital day. 

Two weeks following the onset of illness the 
patient developed large-flake desquamation of 
fingers, palms and soles. The paresthesias had 
completely resolved. Subsequent vaginal cultures 
were negative for CPS on two occasions. The 
patient has completely discontinued the use of 

TABLE 

Toxic-Shock Syndrome Case Definition 

1. Fever (temperature >38.9 C (102 F)). 

2. Rash (diffuse macular erythroderma). 

3. Desquamation, 1-2 weeks after onset, particularly 
palms and soles. 

4. Hsqjotension (systolic blood pressure <90 mm Hg.) 
or orthostatic syncope. 

5. Involvement of three or more of the following organ 
systems: 

A. Gastrointestinal (vomiting or diarrhea). 

B. Muscular (severe myalgia). 

C. Mucous membrane (vaginal, oral, or conjunc- 
tival hypermia). 

D. Renal (BUN or Cr > 2 x ULN or > 5 white 
blood cells per high-power field). 

E. Hepatic (total bilirubin, SGOT, or SGPT > 2 x 
ULN). 

F. Hematologic (platelets < 100,000/mm 1 2 3 ). 

G. CNS (disorientation or alterations of conscious- 
ness). 

6. Negative results on the following tests, if obtained: 

A. Blood, throat, urine, or cerebrospinal fluid cul- 

tures. 

B. Serologic tests for Rocky Mountain Spotted 

Fever, leptospirosis, or measles. 


tampons, and has had two normal menstrual 
periods as of this writing. 

Discussion 

Todd first described TSS as a new entity in 
1978. 1 TSS was distinguished from Kawasaki 
disease by its predilection for older children 
1 8- 1 7y o I and its unique association with 
phage-group-I CPS. A specific exotoxin pro- 
duced by the CPS was felt to be responsible for 
the multi-system involvement as well as the 
characteristic desquamating erythroderma. 

The Center for Disease Control ( CDC ) issued 
a bulletin in 1980 announcing the high pre- 
valence of TSS in menstruating women. 2 CPS 
were cultured from 73 per cent of cases, and 
the overall case-fatality ratio was then as high 
as 15 per cent. Subsequent CDC reports issued 
warnings that the use of specific brands of 
tampons put these women at high risk for 
TSS. 3,4 Later reports, however, proved no 
brand-specific association. 3,6 The table lists the 
criteria for case definition of TSS as issued by 
the CDC. 3 * 

The present case is of interest for several 
reasons. First, our patient presented in a more 
subtle manner than the majority of cases re- 
ported in the early series. 5 8 This may be due 
in part to the fact that we saw the patient within 
the first 12 hours from the time of onset, whereas 
most cases reported were seen on the second 
day. 10 A high index of suspicion led us to make 
an earlier diagnosis than would be allowed by 
the currently accepted criteria. Recently, other 
investigators have suggested that more liberal 
criteria might aid in the earlier recognition of 

TSS. 11 

A second unusual feature of the present case 
was the development of paresthesias of the 
hands. This has been previously reported. 10 
Other reported sequelae to TSS have included 
renal failure, laryngeal paralysis, adult respira- 
tory distress syndrome, alopecia, and recurrent 
episodes of TSS during subsequent menstrual 
periods. 5 

Pathway of Infection 

A third point of interest in our patient was 
the reported infected hair follicle. Although 
we were unable to document this on physical 
examination, it does bear out one theory as to 
the pathway of infection in these patients: 
supposed innoculation of the vagina with CPS 
through the insertion of contaminated tampons. 9 
Our patient must certainly have done this, as 
the temporal relationship between the discovery 


March, 1983, Vol. 79, No. 3 


53 


of the furuncle and the onset of TSS was less 
than one week. 

We began treatment initially with intravenous 
nafcillin sodium specifically directed at the 
suspected CPS colonization of the vagina. This 
course of therapy has been proved to be 
efficacious by other investigators. 3,5,9 The use 
of beta-lactamase-resistant antibiotics has re- 
duced the relapse rate in most series. As of 
this writing, our patient has had two normal 
menstrual periods without relapse. 

Conclusion 

We have presented a case of Toxic Shock 
syndrome with some unusual features, the most 
notable of which was a lack of severity usually 
associated with this disease. Our patient was 
treated specifically with intravenous nafcillin 
sodium, and had a rapid recovery with no 
permanent sequelae and no relapses of TSS. 
We suggest that more liberal criteria be used 
to define TSS in order to allow earlier treatment 
with specific antibiotic therapy as well as general 
supportive measures. 

Acknowledgements 

We would like to thank Loretta E. Haddy, 
State Epidemiologist with the West Virginia De- 
partment of Health, for her assistance in this 
case report. 

Editor's Note: Here are the generic drugs 

and trade names (in parentheses) to which 
reference is made in this manuscript: nafcillin 


sodium (Nafcil), acetaminophen (Tylenol), 

kalin-pectin \ Kaopectate ) , and cloxacillin 

( Tegopen ) . 

References 

1. Todd J, Fishaut M, Kapral F, Welch T: Toxic- 
shock syndrome associated with phage-group-I staphy- 
lococci. Lancet 1978; 2:1116-8. 

2. Morbidity and Mortality Weekly Report. May 23, 
1980; 29(20): 229-30. 

3. Morbidity and Mortality Weekly Report. Sept. 19, 
1980; 29(37):441-4. 

4. Morbidity and Mortality Weekly Report. Jan. 30, 
1981; 30(3); 25-33. 

5. Davis J, Chesney P, Wand P, LeVenture M: Toxic- 

shock syndrome: Epidemiologic features, recurrence, 

risk factors, and prevention. N Engl J Med 1980; 303 
(25): 1429-35. 

6. Shands K. Schmid G, Dan B, Blum D, Guidotti R, 
Flargrett X, Anderson R, Hill D, Broome C, Band J, 
Fraser D: Toxic shock syndrome in menstruating women: 
Association with tampon use and stayhylococcus aureus 
and clinical features in 52 cases. N Engl J Med 1980; 
303(25): 1436-42. 

7. Totte R. Williams D: Toxic shock syndrome. 

Clinical and laboratory features in 15 patients. Ann Intern 
Med 94(2): 149-56. 

8. Fisher R. Goodpasture PI, Peterie J, Voth D: Toxic 
shock syndrome in menstruating women. Ann Intern 
Med 1981; 94(2): 156-63. 

9. Shands K, Dan B, Schmid G: Toxic shock syn- 
drome: The emerging picture (editorial). Ann Intern 

Med 1981; 94(2):264-6. 

10. Chesney P, Davis J, Purdy W, Wand P, Chesney 

R: Clinical manifestations of toxic shock svndrome. 

JAMA 1981; 246(7):741-8. 

11. Tofte R. Williams D: Toxic shock syndrome. 

Evidence of a broad clinical spectrum. JAMA 1981; 
246(19):2163-7. 


54 


The West Virginia Medical Journal 


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'"piMES are tough in West Virginia. The 
economic crunch has hit. Our unemployment 
rate is one of the highest, if not the highest, in 
the nation, and for a great many of these people, 
their health benefits are running out. The De- 
partment of Welfare is attempting to avoid cuts 
in medical services, but because of other budget 
cuts is forced to cut almost all social services 
contracts. The state Public Employees’ Insurance 
Board I responsible for the health benefits pay- 
ments of some 94,000 public employees I is 
projecting a deficit of at least $9 million for 
fiscal year 1983. The Chief Justice of the 
Supreme Court has issued an appeal for contri- 
butions to a food fund to provide food for needy 
families. The doleful litany of economic hard- 
ships continues. 

In my travels throughout the state on your 
behalf, one of the bright spots in this bleak 
economic landscape I have found is the en- 
couraging number of our physicians who are 
contributing their time and talents for little or 
no remuneration. Many are not sending in 
Medicaid claims. Others are writing off bills for 
families in severe economic circumstances, or 
arranging long-term deferred payments. The 
doctors volunteering for the Handicapped 
Children’s Services program devote their time 
far in excess of what they would usually expect 
to receive. These doctors generally do not get 
any kind of credit or publicity for their actions. 
This is a form of “good news,” and good news 
does not sell newspapers or get media attention 
to the extent that had news does. 

Obviously, not all our members can participate 
in these actions. In areas where practices are 


comprised of 40-50 per cent of publically- 
assisted patients, the income from the state may 
he the difference between keeping the office or 
clinic open or shutting it down. Certain areas of 
our state, unfortunately, have more than their 
share of the medically-indigent population, and 
doctors in these areas must utilize all revenue 
sources. I understand this and commend them 
for their provision of quality medical care with 
less than optimum resources. 

The generosity of our physicians who are 
sharing the burden of the economic times with 
their patients is praiseworthy and appreci- 
ated. I would urge you to consider, where 
appropriate, extending and enlarging this gener- 
osity, to insure that those who need quality 
medical care are not hampered in their efforts 
to achieve it by the fear of inability to pay. I 
am not aware of any instance where someone 
who truly needed care was turned away purely 
because of an inability to pay for it. 

So. I personally ask all of you who have not 
considered this before to give it your immediate 
attention. And, for the many of you who have 
been doing this all along; who have been pro- 
viding quality medical care at a considerable 
sacrifice of your time and talents: and who have 
been largely unsung and unpublicized for all this 
time, my hat is off to you. As the song says, 
friends, “This One’s For You! 


d 









Harry Shannon, M. D., President 

West Virginia State Medical Association 


56 


The West Virginia Medical Journal 


The West Virginia Medical Journal 

Editorials 

The Publication Committee is not responsible for the authenticity of opinion or statements made by authors or 
in communications submitted to this Journal for publication. The author shall be held entirely responsible. 
Editorials printed in The Journal do not necessarily reflect the official position of the West Virginia State 
Medical Association 


Conservative estimates place costs of “de- 
fensive medicine” at 30 per cent of total medical 
care costs. Figures such as these are generally 
marshaled in any effort to lay at the feet of 
physicians blame for the towering costs of 
medical care. 

Since these costs are generated for purposes 
of defending the physician from allegations of 
negligence, one is to infer that 
RIGOROUS the v are not only unnecessary but 

STANDARDS even self-serving and selfishly 
motivated. 

It is an attractive argument and one most 
often enthusiastically received by an audience 
primed to damn Medicine and physicians at any 
opportunity. The logic of the argument, how- 
ever, escapes detection in any serious examina- 
tion of the proposition. 

If one can accept the assumption that some 
serious jeopardy faces the physician if he is, 
in fact, found negligent, what then is it in the 
field of negligence against w r hich he seeks to 
defend himself via extraordinary diagnostic 
studies? The answer to this is, of course, that 
the physician seeks to defend himself against 
charges of negligence for failing to uncover a 
rare disease or one totally unrelated to the 
complaints and symptoms of concern bringing 
that patient to the physician in the first place. 

The standard against w 7 hich a physician’s per- 
formance is measured has been escalated to 
rigorous levels. If a patient visits a physician, 
complains of and is treated for an upper 
respiratory infection and turns up a month or 
tw T o later with carcinoma of the pancreas, the 
physician could be found negligent for failing 
to diagnose the occult condition. The visit of 
any new patient or any old patient not recently 
seen thus becomes an occasion demanding a 
sophisticated, time-consuming and very expen- 
sive workup. 

With the physician subject to such a standard 
it is remarkable that rises in medical care costs 
have been so moderate. The control of these 
costs so far demonstrated can only have been 


accomplished at the expense of major risks taken 
by physicians willing to dare the avarice and 
cupidity of predatory plaintiff's attorneys. 

The impossible standard is not one set by 
Medicine. It is set. of course, by the courts, 
aided, abetted, promoted and encouraged by 
some members of the legal profession whose zeal 
to protect patients is exceeded only by that they 
display for fattening their own w 7 allets. 

Who, then, is responsible for the costs at- 
tributed to defensive medicine — the physician 
for using common sense and decent judgment 
in defending himself, or plaintiff’s attorneys and 
the courts for promoting and tolerating the 
imposition of impossible standards? 

The West Virginia State Medical Association 
has prepared for introduction into this session of 
the Legislature bills to effect changes in tort law 
which will have the effect of moderating the risks 
involved in violating the most onerous provisions 
of the impossible medical negligence standard 
presently being applied. Those citizens and 
particularly those legislators with any serious 
intent to help hold down further rises in medical 
care costs should examine these bills closely. 


The idea of prospective reimbursement has 
been getting considerable attention — and has 
been tried in several states — as a possible na- 
tional dollar-saving solution to the upward trend 
in health care costs. 

Such systems function in a generally similar 
fashion. A rate-setting body determines pay- 
ments in advance for services, 
SAVE NOW, cases or diagnoses. Individual 
PAY LATER? hospital patients, or their in- 
surance carriers, must pay those 
rates when admitted to a hospital, regardless of 
length of stay. 

Hospitals may either profit, if patients are 
discharged early; break even; or lose, if patients 
are hospitalized longer than the predetermined 
length of stay. 

David A. Smith, M. D., Medical Editor for 
Pennsylvania Medicine , has expressed some 


March, 1983, Vol. 79, No. 3 


57 



thoughts about prospective reimbursement as 
1982 Medicare amendments have mandated the 
development of such a program for 1983 con- 
gressional consideration. Here are his views: 

‘'If a prospective reimbursement program be- 
comes a national reality within the next few 
years, as it appears that it may, there are three 
areas in which physicians should be prepared 
to respond. The first is quality of care. What 
will be the effect? Will hospital costs be con- 
sidered before quality, and will cost overrule 
quality? 

“The second is malpractice. Will the standards 
that are developed for reimbursement be used 
as evidence in malpractice cases? That is, if a 
physician releases a patient from the hospital 
sooner than the average length of stay de- 
termined for the standard, will vulnerability be 
increased? 

“Third is the continued development of medi- 
cine and medical care. Scientific research will 
be wasted if the new technologies cannot be ap- 
plied to patient care. Will better equipment and 
new services become an unaffordable luxury as 
prospective reimbursement programs reduce 
payment percentages in the name of cost con- 
tainment? 

“While prospective reimbursement programs 
have been touted as the only regulatory 
mechanism showing progress in curbing the rise 
in health costs, we must not be mesmerized by 
the dollar savings in the short term. The long- 
term costs of these programs in terms of en- 
forced acceptance through cost constraints of 
less than top quality medical care may be far 
more expensive than our present, less-than-per- 
fect, system. 

“Like the television commercial suggests, ‘you 
can pay me now or pay me later.’ It implies that 
skimping now probably will be a lot more ex- 
pensive in the long run.” 


The dramatic medical breakthrough in the 
Barney Clark case — the successful implantation 
of a permanent artificial heart in a human 
patient — illustrates once again the amazing 
strides being made in medical technology. 

It also gives pause to thoughtful individuals 
as they consider the long-range 
ON THE implications of this latest example 
ARTIFICIAL of progress. 

HEART Obviously, many years and much 

more testing will be required 
before the artificial heart will be available to aid 


patients on a widespread basis. Eventually, 
however, its widespread use seems likely. 

The unanswered question is cost. Consider 
this example: In 1972, Congress approved 

coverage of renal dialysis for Medicare patients, 
with an estimated cost of about $250 million 
per year. For 1983, the estimated cost is more 
than $2 billion. The cost of the artificial heart 
device alone is more than $16,000. That figure 
is exclusive of all other costs. Any estimate of 
the cost of widespread use of this technique 
would be mere speculation. 

The artificial heart illustrates the capability of 
today's technology and of its brilliant scientists. 
Similar dramatic progress is inevitable in other 
fields. 

Can society afford to make this wonderful new 
technology available to every patient who needs 
it? If not, who shall decide which patients do 
receive it? Medicine and society must make 
some agonizing decisions in the future. - — 
American Medical News, December 17, 1982. 


The above editorial addresses the problem of 
cost of implantation of the artificial heart. Cost 
is not the only “unanswered question. ’ The 
heart is the only organ in the body that has one 
function: it is a simple pump. Between one- 

third and one-half of Americans succumb to 
heart attack or heart fail- 
MORE ON THE ure as a result of damage 

ARTIFICIAL HEART to this pump. It seems 

likely that the technical 
problems that occurred with Barney Clark’s 
artificial heart will soon be corrected and per- 
fected. In the foreseeable future a model which 
can function indefinitely may be available. 

We can speculate that in time implantation of 
an artificial heart could prolong the lives of 
countless thousands, perhaps millions, of Ameri- 
cans. Approximately 15 to 20 per cent of people 
over the age of 70 now suffer from chronic 
dementia requiring custodial or home care by 
other individuals. This could double in the 
next 10 to 20 years. It is not likely that artificial 
livers, lungs, and kidneys — much less brains — 
are on the horizon. 

Adding to life expectancy with artificial 
hearts, without prospect of any means of revers- 
ing the natural aging process, could greatly in- 
crease the number of demented people. Hearts 
that keep on beating and pumping blood to 
organs that continue to wear normally may 
create new problems for society. 

This is not just a problem of medical cost, but 
one of deeper social and ethical significance. 


58 


The West Virginia Medical Journal 


GENERAL NEWS 


AMA President To Speak 
At Annual Meeting 

Dr. Frank J. Jirka. Jr., M. D., who will be 
installed as President of the American Medical 
Association in Chicago in June, will speak 
during the State Medical Association’s 116th 
Annual Meeting in August. Doctor Jirka, a 
urologist practicing in Barrington and Berwyn, 
Illinois, will address the first session of the 
House of Delegates Thursday afternoon. August 
25. 

The convention will be held August 25-27 at 
the Greenbrier in White Sulphur Springs. It will 
open with a pre-convention session of the As- 
sociation’s Council and the first House session 
on Thursday morning and afternoon; and end 
with the second and final House session and 
reception for new Association officers on Satur- 
day afternoon and evening. 

Long active in organized medicine. Doctor 
Jirka was first elected to the AMA Board of 
Trustees in 1974. He served as its Secretary 
in 1976-77 and as its Vice Chairman from 1977 
to 1979. Doctor Jirka has served the Illinois 
State Medical Society as its President. Chairman 
of the Board of Trustees, and as a Delegate to 
the AMA House of Delegates. Currently, he is 
a Councilor of the Chicago Medical Society. 

M. D. from University of Illinois 

Born in Illinois, Doctor Jirka attended Knox 
College in Galesburg, Illinois, before entering 
the University of Illinois College of Medicine 
where he received his M. D. degree in 1950. 
He served his internship and residency at Cook 
County Hospital. Chicago, from 1950-54. Doctor 
Jirka is a Diplomate of the American Board of 
L T rology, and a Fellow of the American College of 
Surgeons and the International College of 
Surgeons. 

Motivated by severe injuries sustained as a 
Navy frogman during World War II, resulting 
in the amputation of both his legs below the 
knee, Doctor Jirka has devoted a great deal of 
his time toward rehabilitation programs. He has 
served on the President’s and the Governor’s 
Committees on Employment of the Handicapped, 
and has been a Board member of the Illinois 


Association of Crippled Children as well as the 
Illinois Rehabilitation Association. 

Doctor Jirka is a Clinical Associate Professor 
in LTology at Loyola University Stritch School 
of Medicine, a Consultant in Llrologv at Hines 
Veterans Administration Hospital, and formerly 
was an Associate Professor in LTrology at Cook 
County Graduate School of Medicine. 

Doctor Jirka and his wife, Pat. have three 
daughters, Lynn J. Sutherland, Mary Pat. and 
Ella Kay. 

Scientific Sessions 

The initial general scientific session, as an- 
nounced earlier, will be a symposium on sexually 
transmitted diseases. It will be held at 9:45 
A. M. on Friday, August 26, preceded by the 
traditional opening exercises. A keynote speaker 
for the latter program will be announced later 
by the Annual Meeting Program Committee. 

David Z. M organ, M. D., of Morgantown, the 
Program Committee Chairman, said the first 



Frank J. Jirka, Jr., M. D. 


March, 1983, Vol. 79, No. 3 


59 



scientific session Friday morning will include 
papers on these individual topics: 

Syphilis and gonococcal infections; non-luetic, 
non-gonococcal venereal diseases; transmissible 
diseases of the gay patient, and sexual mores in 
the 1980s. 

The second general scientific session will be 
held Saturday morning, August 27 and, also as 
announced previously, will be a symposium on 
cardiovascular diseases. The Saturday morning 
topics will include new developments in the 
management of cardiac arrhythmias; an update 
relative to cardiovascular surgery, and the 
management of congestive heart failure. 

Specialty Groups 

In addition to the general sessions, the Annual 
Meeting agenda will include breakfast, luncheon 
and other programs arranged by specialty 
societies and sections, many of which also will 
provide scientific discussions. 

The specialty group meetings will be held in 
large measure on Friday, with a few to be set 
for Saturday morning, preceding the second 
general session, and at noon. 

At the final House session on Saturday after- 
noon, Carl R. Adkins, M. 1)., of Oak Hill will be 
installed as the Association’s 1983-84 President 
to succeed Harrv Shannon, M. D., of Parkers- 
burg. 

Continuing a practice of many years, the 
Auxiliary to the State Medical Association, with 
Mrs. Richard S. Kerr of Morgantown the cur- 


rent President, will hold its meeting in con- 
junction with that of the Association. 

Serving with Doctor Morgan on the 1983 
Program Committee are Doctor Adkins: Jean P. 
Cavender. M. D., Charleston; Michael J. Lewis, 
M. I)., St. Marys; Kenneth Scher, M. D.. 
Huntington, and Roland J. Weisser. Jr., M. D., 
Morgantown. 

Additional information concerning speakers 
and other convention details will he provided 
in upcoming issues of The Journal. 


Infection Control, Tumors 
CME Program Topics 

An Infection Control Workshop and Sym- 
posium on Tumors will be among continuing 
medical education programs offered by West 
Virginia University School of Medicine and 
other sponsors in March. 

The Infection Control Workshop will be held 
Friday afternoon and Saturday morning. March 
25-26, at Lakeview Inn in Morgantown. The 
Program Director will be R. Brooks Gainer II. 
M. I)., WVU Clinical Associate Professor, Sec- 
tion of Infectious Diseases, and Chairman, In- 
fection Control Committee, Monongalia General 
Hospital, Morgantown. The WVU Department 
of Medicine, Section of Infectious Diseases, and 
the hospital are the sponsors. 

The Symposium on Tumors, designed to pro- 
vide the practicing orthopedic surgeon with a 


Some 250 physicians and others attended the 16th Mid-Winter Clinical Conference in Charleston 
January 21-23 under the sponsorship of the State Medical Association and the West Virginia University 
and Marshall University Schools of Medicine. In the left photo, conference material is examined by Drs. 
Joseph T. Skaggs (left) of Charleston, Chairman of the Program Committee, and Harry Shannon, Parkers- 
burg, Association President. On the right are two of the Friday afternoon, January 21, speakers, Drs. Jack 
M. Bernstein (left), Huntington, and Larry I. Lutwick, Brooklyn, New York. 


60 


The West Virginia Medical Journal 


perspective regarding the treatment of bone 
tumors within the community hospital setting, 
is scheduled for March 28-29 at the Greenbrier 
in White Sulphur Springs. 

Material, to be presented entirely by the case 
method, will cover metastatic lesions, benign 
tumors of the bone, malignant tumors, and 
segmental resection. 

Tumor Symposium Faculty 

Members of the faculty will be Drs. William 
Enneking, Distinguished Service Professor of 
Orthopedic Surgery, University of Florida: 
Henry J. Mankin, Edith M. Ashley Professor 
of Orthopedic Surgery, Harvard Medical School, 
and Chief of Orthopedics, Massachusetts General 
Hospital, Boston; John Murray, Clinical As- 
sociate Professor of Orthopedics, Baylor College 
of Medicine and University of Texas at Houston, 
and Chief of Orthopedics, M. D. Anderson 
Hospital and Tumor Institute, Houston; 

Douglas Pritchard, Head of Section. Ortho- 
pedic Oncology, Mayo Clinic, and Associate Pro- 
fessor, Mayo Medical School; Eric L. Radin. 
WVU Professor and Chairman, Orthopedic 
Surgery; Allan Schiller. Associate Professor. 
Pathology. Harvard Medical School and Massa- 
chusetts General Hospital; and Jamshid Tehran- 
zadeh, WVU Assistant Professor of Radiology 
and Chief. Bone Radiology Section. 

Sponsors are the WVU Department of 
Orthopedic Surgery and Office of Continuing 
Medical Education. 


Infection Workshop Speakers 

Speakers and topics for the infection work- 
shop will be: “Making Infection Control 

Applicable to the Patient” — Sue Crow, R.N., 
M.S.N., Nurse Epidemiologist, Louisiana State 
University; “Herpes Simplex — Impact on Pa- 
tient and Staff” — Robert Belshe, M. D., MU As- 
sociate Professor of Medicine and Microbiology, 
Section of Infectious Diseases; “Hepatitis B 
Vaccine — AIDS” — C. Glen Mayhall, M. D., 
Associate Professor of Medicine, Medical Col- 
lege of Virginia; “Infections of Surgical Patients 
and Prevention of Surgical Infections” — Ronald 
Nichols, VI. D., Professor of Microbiology and 
Immunology, Department of Surgery, Tulane 
L niversity; 

“Influenza and Influenza Vaccines" — Robert 
Waldman. M. D., Professor of Medicine and 
Interim Dean. WVU School of Medicine; 
“Hospital-Acquired Pneumonia” — Ronica Kluge, 
M. D., Professor of Medicine, University of 
Texas Medical Branch. Department of Medi- 
cine, Galveston: “Tuberculosis in the Hospital" 
— Rashida Khakoo, M. D.. WVU Associate Pro- 
fessor of Medicine, Division of Infectious 
Diseases; 

California Speaker 

"Infections in the Compromised and Im- 
munosuppressed Patient" — Lowell Young, M. D., 
Professor of Medicine, Division of Infectious 
Diseases, University of Southern California, Los 



Shown in the left photo is Gary A. Banas (center), Akron (Ohio) attorney, speaker for the Physicians’ 
Session of the 16th Mid-Winter Clinical Conference held in January in Charleston. The session was 
entitled, “The Doctor, Quality Control and Professional Liability.” With Banas are John F. Wood (left), 
Huntington attorney, and Dr. Jack Leckie, also of Huntington, panelists. On the right are panelists Tom 
Auman (left), Director of Professional Liability, McDonough Caperton Shepherd Association Group, Charles- 
ton: and attorney Fred Bockstahler, Director of Patient Affairs, Charleston Area Medical Center. Not 
shown is panelist James C. Crews, CAMC President. 


March, 1983, Vol. 79, No. 3 


61 



Angeles; "In-Hospital Staphylcoccal Infections” 
— Chatrchai Watanakunakorn, M. D., Professor 
of Internal Medicine, College of Medicine, 
Northeastern Ohio University; and “Current 
Concepts of the Pathogenesis and Rational 
Measures for Prevention of Infection due to 
Intravascular Devices” — Dennis G. Maki, M. D., 
Professor of Medicine, Section of Infectious 
Diseases, University of Wisconsin. 

For registration and additional information 
concerning either meeting, telephone the WVU 
Office of Continuing Medical Education at 
(304) 293-3937. 


Chapter Plans 16 Papers 
For April Meeting 

“Recent Advances in Treatment of Headaches 
in Children ’ will be among some 16 papers to 
be presented during the 31st annual scientific 
assembly of the West Virginia Chapter, Ameri- 
can Academy of Family Physicians. 

The meeting will be held April 15-17 in 
Morgantown at the Lakeview Inn and Country 
Club. 

The talk on headaches in children will be 
given Sunday morning, April 17, by Arnold D. 
Rothner, M. D., Chief, Section of Child 
Neurology, The Cleveland Clinic Foundation. 

In addition to the concluding Sunday morn- 
ing session, scientific sessions also will be held 
Friday morning and afternoon, and Saturday 
morning and afternoon. 

Senile Dementia 

Some of the other speakers will be James 
T. Hartford, M. D., Associate Professor and 
Chief, Geriatric Psychiatry, University of 
Cincinnati Medical Center, on “Senile Dementia" 
(Sunday morning); Thomas Roth, Ph.D., 



Arnold D. Rothner, M. D. James T. Hartford, M. D. 



Thomas Roth, Ph.D. 



Joseph M. Pitone, D. O. 


Director, Sleep Disorders and Research Center, 
Henry Ford Hospital, Detroit, “Now I Lay Me 
Down to Sleep . . . Insomnia" (Saturday morn- 
ing); and Joseph M. Pitone, D.O., Assistant 
Professor of Medicine, Department of Nephro- 
logy and Hypertension, University of Medicine 
and Dentistry of New Jersey, New Jersey School 
of Osteopathic Medicine; and Head, Subsection, 
Department of Nephrology and Hypertension, 
John F. Kennedy Memorial Hospital, Stratford 
I New Jersey) Division. "Hypertension Treat- 
ment for Family Physicians" (Saturday after- 
noon I . 

Other subjects to be discussed will include 
physician exercise and fitness; the impaired 
physician; office management; peptic ulcer 
disease: low back pain; beta blockers; throm- 
bolytic therapy in venous thromboembolic 
disease; and rheumatology. 

I See story in the February issue of The 
Journal for a complete list of speakers and 
topics. ) 

The program is acceptable for 18 and one- 
half Prescribed hours by the AAFP, and is 
approved for the same number of hours in 
Category 1 of the Physician's Recognition Award 
of the American Medical Association. 

Other Activities 

The Chapter’s House of Delegates will hold 
a noon luncheon meeting on Friday, and the 
Board of Directors will meet at 6 P. M. Thurs- 
day, April 14, and 1 P. M. Sunday. The annual 
banquet session is scheduled for 7:30 P. M. 
Saturday. 

A breakfast meeting at 7 o’clock Sunday will 
be held by the Board of Directors of the Family 
Medicine Foundation of West Virginia. 

Family Physicians will be welcomed to the 
scientific assembly by Dr. Robert D. Hess of 
Clarksburg, President. 


62 


The West Virginia Medical Journal 



WVU Charleston Geriatric 
Program March 16 

Geriatric Update '83. a half-day continuing 
medical education program, will be held in 
Charleston on Wednesday afternoon. March 16. 

The meeting site will be the West Virginia 
University Medical Center Education Building 
at 3110 MacCorkle Avenue, S.E. 

By attending this program, participants will 
be able to determine effective usages of drugs 
and multiple drugs in care of the elderly patient, 
identify depressive states in the elderly, and 
understand current concepts in sleep patterns in 
the aged patient. 

Faculty members will be: Mary Beth Gross, 
Pharm. D., Assistant Professor of Clinical 
Pharmacy, WVU Charleston Division; Albert 
Heck, M. D., Clinical Associate Professor of 
Neurology, WVU Charleston Division: Donald 
S. Robinson, M. D., Chairman, Department of 
Pharmacology, and Professor of Pharmacology 
and Medicine, Marshall University School of 
Medicine; and Thomas Roth, Ph.D.. Director, 
Sleep Disorders and Research Center, Henry 
Ford Hospital, Detroit. 

The program is approved for four credit hours 
in Category 1 of the Physician’s Recognition 
Award of the American Medical Association. 

For additional information contact WVU 
Conference Services at (304) 347-1242. 


Continuing Education 
Activities 


Here are the continuing medical education 
activities listed primarily by tbe West Virginia 
University School of Medicine for part of 
1983, as compiled by Dr. Robert F. Smith, 
Assistant Dean for Continuing Education, and 
J. Zeb Wright, Ph. D., Coordinator, Con- 
tinuing Education. Department of Community 
Medicine, Charleston Division. The schedule is 
presented as a convenience for physicians in plan- 
ning their continuing education program. (Other 
national, state and district medical meetings are 
listed in the Medical Meetings Department of 
The Journal. ) 

The program is tentative and subject to 
change. It should be noted that weekly confer- 
ences also are held on the Morgantown, Charles- 
ton and Wheeling campuses. Further information 
about these may be obtained from: Division of 
Continuing Education. WVU Medical Center, 
3110 MacCorkle Avenue, S. E., Charleston 
25304: Office of Continuing Medical Education, 
WVU Medical Center, Morgantown 26506; or 
Office of Continuing Medical Education. Wheel- 
ing Division. WVU School of Medicine, Ohio 
V alley Medical Center. 2000 Eoflf Street, Wheel- 
ing 26003. 

(continued on next page) 



Shown in the left photo are, from left, Drs. Tony C. Majestro, Charleston orthopedic surgeon, and Frank 
C. McCue III of Charlottesville, Virginia, who spoke to physicians on sports medicine during the recent 
Mid-Winter Clinical Conference in Charleston. Doctor McCue also was the speaker for the Friday evening 
public session on medical care for the athlete. Doctor Majestro presided at the public session. On the 
right. Dr. James W. Kessel (left) of Charleston, speaker on trauma transport, chats with Dr. and Mrs. 
J. C. Huffman of Buckhannon. 


March, 1983, Vol. 79, No. 3 


63 




March 16, Charleston, Geriatric l pdate ’83 

March 18, Charleston. 10th Annual Newborn 
Day 

March 25-26, Morgantown. Infection Control 
Workshop 

March 28-29. White Sulphur Springs, Sym- 
posium on Tumors for the Orthopedic 
Surgeon 

April 28, Wheeling, Balance Disorders 

April 29, Charleston, Research Day 

April 29-30. Morgantown, Orthopedic Reunion 
Days 

May 7, Charleston, Outpatient Infectious Dis- 
eases 

May 12-13. Morgantown, Health Officers Con- 
ference 

June 3-4, Morgantown, Anesthesia Update ’83 

June 4, Charleston, 10th Annual Wildwater 
Conference — Medical & Surgical Update 

Regularly Scheduled Continuing 
Education Outreach Programs from 
WVU Medical Center/ 
Charleston Division 

Buekhannon , St. Joseph’s Hospital, first-floor 
cafeteria, 3rd Thursday, 7-9 P. M. — March 
17, “Thyroid Dysfunction: Diagnosis and 

Management,' Richard Kleinmann, M. D. 

April 21, “Prenatal Disorders and Congenital 
Anomalies,” R. Stephen S. Amato. M. D. 

May 19, “Evaluation of Infertility and Fre- 
quent Spontaneous Abortions,” Bruce U. 
Berry, M. D. 

Cabin Creek, Cabin Creek Medical Center, 
Dawes, 2nd Wednesday, 8-10 A. M. — March 
9, “Overall Outpatient Management of Renal 
Dysfunctions,” Mary Uou Lewis, M. D. 

Cassaway, Braxton Co. Memorial Hospital. 1st 
Wednesday, 7-9 P. M. — March 2. “Enteral 
Alimentation." Brittain Mcjunkin, M. D. 

April 6, “Clinical Intervention in Drug & 
Alcohol Abuse,” Thomas Haymond, M. D. 

Madison, 2nd floor. Lick Creek Social Services 
Bldg., 2nd Tuesday, 7-9 P. M. — March 8. 
"Drug & Alcohol Abuse: Intervention Strate- 
gies," Thomas Haymond, M. 1). 


Oak Hill. Oak Hill High School I Oyler Exit, N 
19 1 4th Tuesday, 7-9 P. M. — March 22. 
“End-Stage Renal Disease,” Mary Lou Lewis, 
M. D. 

April 26. “Adolescent Sexuality: Recognizing 
& Treating Pathological Behavior.” T. 0. 
Dickey, M. D. 

Welch, Stevens Clinic Hospital. 3rd Wednesday, 
12 Noon-2 P. M. — March 16. “Protocols 
for Treating Poisonous Snake Bites. ’ David 
O. Wright, M. D. 

April 20, “Emotional Trauma of Cancer,” 
Sr. Frances Kirtley. R.N., and Sue Warren, 
M. D. 

Whitesville, Raleigh-Boone Medical Center, 4th 
Wednesday, 11 A. M.-l P. M. — March 23. 
"Hypertension Update: Diagnosis & Manage- 
ment," Stephen Grubb. M. D. 

April 27, “Obesity: Emotional Factors in 

Compliance,” John Linton, Ph.D. 

IVilliamson, Appalachian Power Auditorium, 1st 
Thursday, 6:30-8:30 P. M. — March 3, 
“Suicide Intervention.” Martin Kommor. 

M. D. 


Review A Book 


The following books have been received by the 
Headquarters Office of the State Medical Associa- 
tion. Medical readers interested in reviewing any 
of these volumes should address their requests to 
Editor. The West Virginia Medical Journal, Post 
Office Box 1031. Charleston 25324. We shall be 
happy to send the books to you. and you may 
keep them for your personal libraries after sub- 
mitting to The Journal a review for publication. 

Basic and Clinical Pharmacology, by Bertram 
G. Katzung, M. D., Ph.D. 815 pages. Price 
$23.50. Lange Medical Publications, Los Altos. 
California 94022. 1982. 

Nine Months' 1 Reading : A Medical Guide for 
Pregnant W omen, 3rd Edition, by Robert E. 
Hall, M. D. 178 pages. Price $13.95. Double- 
day & Company, Inc., 245 Park Avenue, New 
York. New York 10167. 1983. 

Living With Herpes, by Deborah P. Langston. 
M. I). 198 pages. Price $7.95. Doubleday & 
Company, Inc., 245 Park Avenue, New York. 
New York 10167. 1983. 


64 


The West Virginia Medical Journal 



Council Acts On Trauma 
Centers, Loan Fund 

The State Medical Association’s Council, at 
its January 16 meeting, endorsed the concept 
of designating West Virginia hospitals as trauma 
centers, following the criteria of the American 
College of Surgeons. 

The action was taken following a presentation 
by Dr. Frederick M. Cooley of Charleston, 


Director. Emergency Medical Services of the 
State Health Department. 

Doctor Cooley proposed that the State Health 
Department be empowered to designate West 
\ irginia hospitals as trauma centers following 
application by an interested hospital and a site 
inspection visit to the hospital. 

The Council also unanimously sanctioned 
contributions to the Clark K. Sleetli Medical 



Speakers for the Saturday afternoon session on pediatric topics during the Mid-Winter Clinical Con- 
ference are shown with Dr. Herbert H. Pomerance (second from right) of Charleston, who presided. They 
are, from left, Drs. Martin R. Klemperer and Roberta Gray, both of Huntington, and R. Stephen S. Amato 
of Morgantown. In the right photo, Dr. Stephen L. Sebert (left) of Fairlea (Greenbrier County), has a 
conversation with Dr. William O. McMillan, Jr., of Charleston, member of the Program Committee. 



Dr. William H. Nelson of Farmington, Connecticut, a psychiatrist who was a speaker for the Sunday 
morning session of the Mid-Winter Clinical Conference, is shown in the left photo. In the right photo, 
the other Sunday morning speakers go over the program with Dr. John W. Traubert (center) of Morgan- 
town, who presided. They are Drs. Robert C. Touchon, left, Huntington cardiologist, who talked on 
calcium channel blockers, and George W. Weinstein, Morgantown ophthalmologist, whose subject was 
lens replacement. 


March, 1983, Vol. 79, No. 3 


65 



Student Loan Fund in memory of the late Doctor 
Sleeth, former Dean of the West Virginia Uni- 
versity School of Medicine, who died last 
November. Checks may be made payable to the 
“WVU Foundation,” and it is suggested that the 
following be written in the lower left corner: 
“This contribution for the Clark K. Sleeth Medi- 
cal Student Loan Fund.” Checks may be sent 
to Dr. David Z. Morgan, Associate Dean of the 
WVU School of Medicine, Morgantown 26506. 

In other action. Council: 

— Heard an update on the Association- 
endorsed professional liability insurance pro- 
gram with CNA of Chicago as the carrier by Dr. 
Jack Leckie of Huntington, Chairman of the As- 
sociation's Committee on Insurance. 


— Elected to honorary membership, after 
appropriate component society action, Dr. Lysle 
T. Veach of Petersburg. 

—Heard a review by staff members Robert F, 
Bible, Staff Counsel, and Charles R. Lewis, 
Executive Secretary, of medicine-related legisla- 
tion introduced to date in the State Legislature. 

— Elected or re-elected the following as 
nucleus members of the West Virginia Political 
Action Committee Board: Dr. Stephen D. Ward 
of Wheeling, First Congressional District; Dr. 
John L. Fullmer of Morgantown, Second Con- 
gressional District; Dr. Joseph T. Skaggs of 
Charleston, Third Congressional District; Dr. 
Frank J. Holroyd of Princeton, Fourth Congres- 
sional District, and Dr. Thomas F. Scott of 
Huntington and Bible as ex officio members 


An Open Letter 

To West Virginia’s Physicians and Others: 

As the years add up, and one gets along in 
life, it’s not uncommon for a wheel or two to 
come off — sometimes not only unexpectedly, 
but in a hurry. That’s what happened to me 
in recent weeks. 

As members of the Executive Committee, 
Council and some others were aware, through 
myself, Drs. Carl Hall and John Markey, 
discovery of a rectal-area malignancy led very 
quickly to a colostomy. The post-operative 
prognosis appears at this point (February 6) 
most favorable; I’m at home recuperating, 
and I feel great. 

There is just no way in which I can ever 
express to you individually my gratitude for 
your prayers; your many cards; flowers; 
telephone calls to the hospital, the Association 
office and my home; and the visits to the 
hospital by a number of physicians and others. 

Completely inadequate that it might be, 
this message to the members of the Associa- 
tion accordingly is the only way I feel I have 
of expressing the deep-felt gratitude of my- 
self, Jane and all the other members of my 
family. 

I must confess to a feeling, also, of humble 
pride in the concern and interest from every 
part of the state and the physician com- 
munity. We certainly have always made it our 
first order of business, as a state office, to 
exert every bit of effort to make the Associa- 
tion what its constitution says it shall be — and 


1 have new confidence, gained through an 
admittedly unexpected channel — that we at 
least are headed in a strong and correct 
direction. 

Under the current circumstances, a renewed 
expression of gratitude also is in order for 
the other members of the headquarters staff — 
Custer Holliday, Bob Bible, Mary Hamilton, 
Sue Shanklin, Mary Sue Smalley and Beverly 
O’Dell. 

As I have often said, excluding my own 
12 years with the Association and the Medical 
Institute, this staff represents some 60 years 
of service, expertise and dedication to the 
State Medical Association, its members and 
the people of this state. In this day and time, 
that kind of situation is virtually unheard of. 

Staff was aware in every detail of what I 
faced; what my limitations would be for at 
least a little while; and some shifting and 
increase in workloads. They haven't missed 
a beat, with Custer doing his usual super job 
with the Mid-Winter Conference and the 
others right in step. 

I’m proud of, and grateful for, that kind 
of support. And by the time you read this, I 
expect — with my doctor’s close direction, of 
course — to be for the most part back in the 
saddle and at least able to handle the major 
issues at hand. 

God bless you one and all, 

Charles R. Lewis 

Executive Secretary 


66 


The West Virginia Medical Journal 


representing the Council and the State Medical 
Association staff, respectively. 

— Approved the payment of round-trip air 
fare for a representative to the meeting of the 
residents section at the annual meetings of the 
American Medical Association ( pending final 
approval of a membership category for residents 
by the State Association's House of Delegates 
at the Annual Meeting next August). 

— Approved the transfer of the Association 
employee benefit plan from the Connecticut 
Mutual Life of Hartford, Connecticut, to the 
Kanawha Valley Bank in Charleston. 

— Heard comments by Dr. L. Clark Hans- 
barger. State Health Director, on the State 
Health Department budget, legislation sponsored 
by the Department, and the rationale behind the 
announced closing of Spencer State Hospital. 

— Reconfirmed previous Council action in en- 
dorsing a collection service offered by I. C. 
System, Inc., of St. Paul, Minnesota. 


Pain Killers Underutilized, 

AMA President Says 

Physicians frequently underutilize pain medi- 
cations for terminal patients, American Medical 
Association President William Y. Rial, M. D., 
said at a recent AMA conference on severe 
chronic pain. Every day, thousands of patients 
suffer unnecessarily because a drug is admin- 
istered in inadequate doses or excessively long 
dosing intervals, he said. 

Doctor Rial noted that patients often are 
reluctant to reveal the severity of their pain or 
to take narcotics. Hospital staffs and relatives 
often have a misguided concern that the 
terminally ill patient will develop a drug de- 
pendence, he said at the Conference on the Care 
of Patients with Severe Chronic Pain in 
Terminal Illness, which was co-sponsored by the 
U.S. Public Health Service. 

“It is the responsibility of every physician 
and all others who serve patients to understand 
the dynamics of pain, to understand the 
pharmacologic activity of analgesics, and, most 
importantly, to work with and understand the 
needs of each patient and the family,” Doctor 
Rial said at the conference in Washington, D. C. 

The conference coincided with the reintroduc- 
tion of a bill by Sen. Daniel Inouye (D, Hawaii) 
that would legalize heroin for use in relieving 
pain for terminal patients. 

“I personally do not believe that legalizing 
heroin or making it more available is necessary 

March, 1983, Vol. 79, No. 3 


for the treatment of patients,” Assistant Secre- 
tary for Health Edward N. Brandt, Jr., M. D., 
told the AMA. “The other analgesics that are 
on the market are equally potent, and the new 
ones that are being developed are up to six times 
more potent than heroin.” 

Rescheduling heroin would lead to illegal 
trafficking and promote drug abuse that can 
ruin the lives of children and young adults, said 
Doctor Brandt, who was a speaker at the con- 
ference. 


Clark K. Sleeth Memorial 
Started By AAFP 

A Clark K. Sleeth, M. D., Memorial Fund 
has been established by the West Virginia 
Chapter, American Academy of Family Physi- 
cians through the Academy’s Family Medicine 
Foundation of West Virginia. 

The action was taken by the Academy at its 
January meeting in Charleston to honor the late 
Doctor Sleeth, a former Dean of the West Vir- 
ginia University School of Medicine and the 
first Chairman of the WVU Department of 
Family Practice. Doctor Sleeth died last 
November 30. 

Proceeds from the memorial fund will be 
channeled into the Foundation’s regular pro- 
grams, including support for family practice 
residency programs, family practice clubs for 
undergraduates, and student scholarships. 

Checks should be payable to the Family 
Medicine Foundation of West Virginia, and sent 
to the Foundation at P. 0. Box 7058, Cross 
Lanes, Charleston 25313-0058. 


AMA Takes Strong Stand 
On Drunk Driving 

The American Medical Association has noted 
its support of incentive grants to states that 
voluntarily improve their laws and traffic safety 
programs to curtail drunk driving accidents. 
Enacted by the last Congress, PL 97-364 will 
“encourage and enable the states to increase and 
improve their efforts to reduce the number of 
drunk drivers on the road,” the AMA said 
recently in comments on the advance notice of 
proposed rule-making to implement the law. 

To be eligible for the supplementary funds, 
the states must ( 1 ) suspend the driver’s licence 
for at least 90 days on the first conviction, (2) 
sentence repeaters to at least 48 hours in jail 
or to 10 days’ community service, (3) recognize 

67 


0.10- per cent blood alcohol concentration as the 
legal measure of intoxication, and I 1 ) increase 
efforts to enforce alcohol-related traffic laws and 
to let the public know of such enforcement. 

A state may participate in the program for 
a maximum of three years. The federal share 
will diminish from 75 per cent in the first year, 
to 50 per cent in the second year, and to 25 
per cent in the third year. A total of $25 million 
has been authorized for fiscal year "83. and $50 
million each for fiscal year '84 and fiscal year 
'85. 

AMA Leader Speaks 

‘'Let’s get drunk drivers off the road.” AMA 
Executive Vice President James H. Sammons, 
M. D., said at a recent meeting of the Alliance 
Against Intoxicated Motorists ( AAIM ) in 
Chicago. “Drunk drivers are responsible for an 
epidemic of tragic human carnage on our roads 
and highways,” said the AMA leader, who stated 
that about 27.500 Americans are killed and 
about 700.000 people are seriously injured in 
alcohol-related traffic accidents each year. 

“If you visited the emergency room of a 
community hospital during the late night or early 
morning hours on any Friday or Saturday, when 
drunk drivers are most prevalent, you would 
probably conclude that our roads and highways 
have become a battlefield. In that emergency 
room, you would find physicians and other 
health professionals desperately trying to save 
the maimed victims of a drunken driver." 

A featured speaker on the program was 
nationally syndicated advice columnist Ann 
Landers, who declared that drunken driving is 
a “national disgrace.” “We have got to do some- 
thing about the judges who keep letting these 
guys off.” said Landers, who is a member of the 
President's Commission on Drunk Driving. She 
supported state efforts to reduce alcohol-related 
accidents among young people by raising the 
drinking age from 18 to 21 years of age. 

Past AMA Action 

Through the years, the AMA House of Dele- 
gates has taken a number of actions to stop 
drunk driving. In 1960, the House recommended 
that a blood alcohol level of 0.10 per cent should 
he accepted as prima facie evidence of legal in- 
toxication. In 1981, it called on state and 
specialty societies to seek enactment of more 
stringent drunk driving laws in all the states. 

At the meeting last December in Miami 
Beach, the House directed the AMA to provide 
even stronger support for state and federal 
legislation. 


Medical Meetings 


March 4-6 — Am. Medical Student Assoc., Cleevland. 

March 5-12, Canadian Am. Medical Dental Assoc., 
Vail, CO. 

March 10-15 — Am. Academy of Orthopedic Sur- 
geons, Anaheim, CA. 

March 20-24 — Am. College of Cardiology, New Or- 
leans. 

April 7-8 — WV Chapter, Am. Academy of Pediatrics, 
Beckley. 

April 11-14 — Am. College of Physicians, San 
Francisco. 

April 15-17 — WV Chapter, AAFP, Morgantown. 

April 16-21 — Am. Academy of Pediatrics, Phila- 
delphia. 

April 17-21 — Am. Urological Assoc., Las Vegas. 

April 17-22 — Operative Treatment of Fractures & 
Nonunions (Johns Hopkins University), Hot 
Springs, VA. 

April 18-22 — Am. Roentgen Ray Society, Atlanta. 

April 22-24 — Medical Staff Leadership Seminar 
(Southern Medical Assoc.), Hilton Head, SC. 

April 23 — WV Diabetes Assoc., Charleston. 

April 24-28 — Am. Assoc, of Neurological Surgeons, 
Washington, D. C. 

May 4-7 — WV Chapter, Am. College of Surgeons, 
White Sulphur Springs. 

May 6-8 — Southern Medical Assoc. Regional Post- 
graduate Conference, Lexington, KY. 

May 8-12 — Am. College of Obstetricians & Gyne- 
cologists, Atlanta. 

May 13-14 — Topics in Cardiovascular Diseases (Am. 
Heart Assoc.), Baltimore. 

May 26-28 — Am. Assoc, of Genitourinary Surgeons, 
White Sulphur Springs. 

June 19-23 — Annual Meeting of AMA House, Chi- 
cago. 

Aug. 25-27 — 116th Annual Meeting, VV. Va. State 
Medical Assn., White Sulphur Springs. 

Sept. 29-Oct. 2 — Am. Society of Internal Medicine, 
San Francisco. 

Oct. 16-21 — Am. College of Surgeons, Atlanta. 

Nov. 6-9 — Scientific Assembly, Southern Medical 
Assoc., Baltimore. 


68 


The West Virginia Medical Journal 





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WVU Medical Center 
-News— 


i 

i 



Compiled from material furnished by the Medical Center 
News Service, Morgantown, W. Vo. 


Medical Graduate Return Rate 
Above National Average 

West Virginia University is returning a good 
percentage of its medical graduates to practice 
in West Virginia, in numbers better than the 
national average, according to Interim Dean 
Robert H. Waldman, M. D., of the School of 
Medicine. 

Doctor Waldman's comments were in response 
to concerns, in a time of major state financial 
difficulties, over whether the state’s medical 
schools are meeting its health manpower needs. 

"It makes us very unhappy to hear it said 
that West Virginia University is not returning 
its medical graduates to West Virginia to 
practice medicine,” Doctor Waldman said. 

‘Proven Track Record’ 

“Furthermore, unlike some medical schools, 
we are not just talking about our good intentions. 
We’re not just planning to produce doctors for 
West Virginia; we have a proven track record 
of graduates remaining in West Virginia to 
practice.” 

Doctor Waldman said WVU medical graduates 
“are also choosing medical specialties most 
widely needed in a rural state such as ours, and 
many are practicing in areas of the state that 
have been short on doctors.” 

Nationwide, less than 40 per cent of all 
physicians are practicing in the state where they 
received their M. D. degrees. The figure is 
even lower among most small states. 

“Against these figures, West Virginia Uni- 
versity stands up well,” Doctor Waldman said. 
“Of the 766 WVU medical students who earned 
their M. D. degrees during the 1970s, 41.1 per 
cent are practicing in West Virginia. 

“The figures look even better when you con- 
sider the past five years: except for a slight lag 
in 1978, the percentage of our graduates re- 
maining in West Virginia has been near 50 per 
cent since 1974." 


The percentage of West Virginia physicians 
who are WVU graduates increased by 89.5 
per cent between 1972 and 1982. 

WVU graduates who remain in West Virginia 
also tend to choose to specialize in the areas 
of greatest need. The top five specialties of 
WVU medical graduates who are practicing in 
West Virginia are internal medicine, family 
practice, general surgery, psychiatry, and 
obstetrics and gynecology. 

Nearly 60 per cent of the WVU medical 
graduates who chose family practice or general 
practice as their specialty have remained to 
practice in West Virginia. 

In addition, physicians who do their post- 
graduate training at WVU — whether or not they 
earned their M. D. degree in West Virginia — 
tend to remain in the state. 


Doctor Gutmann Serving 
On National Board 

Uudwig Gutmann. M. D., Chairman of 
Neurology, has accepted an invitation to serve 
on the National Board of Medical Examiners. 

The hoard designs and regularly updates 
examinations used in the licensing of physicians 
and national testing of medical students. About 
80 per cent of all U. S. medical graduates are 
licensed to practice through NBME certification, 
and 52 of the 55 licensing authorities in the 
U. S. and Canada accept National Board certifi- 
cations without requiring further examination. 

Doctor Gutmann will serve on the Medicine 
Test Committee for Part II, which develops the 
content of National Board examinations for 
medical students in medicine and neurology. 

NBME test committees include more than 
100 men and women chosen from among 
prominent members of medical faculties through- 
out the U. S. and Canada. They were described 
as “the best qualified leaders in medicine” by 
Edithe J. Uevit, director of the NBME, which 
was established in 1915 and has principal offices 
in Philadelphia. 

Doctor Gutmann joined the WVU medical 
faculty in 1966. 


xvi 


The West Virginia Medical Journal 


I 7 ) ) WHEELING HOSPITAL 

Medical Park, Wheeling WV 26003 


Announces The Third Continuing Education Course 

On 

BALANCE DISORDERS 

Thursday, April 28, 1983 

(''Vp/'j 1 + o’ Approved for 7 Credit Hours Category I for the Physician's Recognition Award of the 

AMA. Acceptable for 7 Prescribed Hours by the American Academy of Family Physicians. 


QOU TSG’ "^' S course ' s designed for the family practitioner and the many various specialists 
seeking better understanding and improved competence in the diagnosis and 
management of the patient with any form of dizziness or diseguilibrium. The 
registration fee is $30.00 and includes the course-related materials, luncheons, 
refreshments and cocktails. The topics covered will include: 


Topics: 


Bone Marrow Examination, Clinical Application; Plasma Cell and Blood Protein 
Disorders; Auditory Brainstem Evoked Potentials, ENG, Impedance Audiometry, 
Application to Clinical Otology; Management of Otitis Media in Children; Surgical 
Management of Vertigo; Recent Advances in Anti-Microbial Therapy; Hyperlipidemia; 
Parkinsonism, Plus Syndrome; Hypoglycemia; Clinical Management of Acute 
Hypersensitivity Syndrome. 


Chairman: 


Hong I. Seung, M.D., Clinical Assistant Professor, Otolaryngology-Head and Neck 
Surgery, West Virginia University School of Medicine, Morgantown, West Virginia. 

Senior Staff, Wheeling Hospital and Ohio Valley Medical Center, Wheeling, West Virginia 


Speakers: 


Joseph R. Bianchine, M.D., Professor and Chairman, Department of Pharmacology; 
Professor of Medicine, Ohio State University, College of Medicine, Columbus, Ohio. 



rk j 

C C; ' 


Thaddeus S. Danowski, M.D., Clinical Professor of Medicine, University of Pittsburgh, 
School of Medicine; Director of Medicine, Shadyside Hospital, Pittsburgh, Pennsylvania. 


Heinz F. Eichenwald, M.D., Professor and Chairman, Department of Pediatrics, 
University of Texas, Health and Sciences Center, Dallas, Texas. 


Michael Glasscock III, M.D., Clinical Professor of Otolaryngology, Vanderbilt University, 
School of Medicine, Nashville, Tennessee. 

Bong H. Hyun, M.D., D. Sc., Professor of Pathology, Rutgers Medical School; 

Director, Department of Pathology, Muhlenberg Hospital, Plainfield, New Jersey. 


Lodging: 


Overnight Accommodations: Physicians should directly contact the reservation manager 
of hotel or motor inn of their choice. Suggestions: Howard Johnson's 1-800-654-2000 
and Wheeling Inn (304) 233-8500. For golf reservations at Oglebay Park’s Speidel 
Course, call (304) 242-3000, Extension 156. For tennis reservations, (304) 242-3770 
(indoor, Wheeling Park) or (304) 242-3000, Extension 139 (outdoor, Oglebay Park). 

For further information contact Dr. Elliott at Wheeling Hospital (304) 242-7870. 


Registration Form 

BALANCE DISORDERS 

Thursday, April 28, 1983 

Name Specialty 

Address City State 


Registration fee is $30.00. Please make checks payable to Wheeling Hospital and mail with this form to Terry 
Elliott, M.D., Continuing Medical Education, Wheeling Hospital, Medical Park, Wheeling, WV 26003. 


Third-Party News, Views 
and Program Concerns 



Health Care Competition 
Policy On Horizon 


The Reagan Administration continues to move 
toward its long-awaited proposal to inject more 
competition into the health care economy, the 
American Medical Association has observed. 

Speaking before a recent national health 
maintenance organization I HMO I policy con- 
ference in Washington. White House health 
consultant David A. Winston said he had reason 
to believe a competition policy would be intro- 
duced “very soon.” The annual meeting was 
sponsored by the Group Health Association of 
America and the American Association of 
Foundations for Medical Care. 

Winston, an unpaid special consultant with 
responsibility for coordinating the development 
of an Administration strategy for health care 
reform, predicted that the proposal would in- 
clude a so-called “tax cap." limiting the dollar 
amount of health care benefits that are non- 
taxable to the employee, and mandatory cost 
sharing for certain Medicare patients. 

He was less optimistic about the proposal’s 
chances for enactment, saying he could not pre- 
dict whether such a proposal would pass. He 
was convinced, however, that top-level Admini- 
stration officials were committed to making the 
health care system more responsive to price. 

Proposal Lags 

Discussing why the Administration s plans for 
a so-called “pro-competition proposal had 
lagged for two years. Winston said the Admini- 
stration assessment was that “almost anything 
would irritate almost everyone.” 

For a period, he said, “we thought seriously 
that the smartest political thing” was to do 
nothing. More recently, data on current and 
projected health care expenditures made the 
Administration take notice of a pressing need 
for changes, he added. 


Winston said the S56.4 billion spent on Medi- 
care in 1982 year would grow, by conservative 
estimate, to $100 billion by 1987 if no reforms 
were enacted. Six weeks ago, health care ex- 
perts, briefing the President and other top 
Administration officials, estimated that total 
health care expenditures in the nation would 
grow to $798 billion by 1990 if the current 
system was allowed to stand. 

Acknowledging that the Administration was 
supporting an unpopular proposal. Winston said 
everyone would suffer “a certain amount of 
pain" and undergo constraints to accomplish the 
long-term goal of helping consumers become 
more prudent buyers of health care. 


AMA Supports Streamlined 
FDA Drug Approval 

The American Medical Association has gone 
on record as supporting proposed rule changes 
that would streamline U. S. Food and Drug Ad- 
ministration approval of new drugs. A number 
of the provisions in the proposed rule are close 
to draft amendments to the Food, Drug, and 
Cosmetic Act that were developed by the AMA 
in 1977. and also are similar to recommendations 
of the Commission on the Federal Drug 
Approval Process. 

The AMA has long been concerned about the 
so-called “drug lag.' AMA Executive Vice Presi- 
dent James H. Sammons. M. IT, said in a letter 
to FDA Commissioner Arthur Hull Hayes Jr., 
M. D. Because of the FDA’s time-consuming 
approval procedures, important new drugs 
reached the market in foreign countries well be- 
fore they were available in the United States. 
By eliminating unnecessary regulation require- 
ments. the proposed FDA rule changes will make 
drugs available for patients “in the shortest pos- 
sible time consistent with safety and effective- 
ness. Doctor Sammons said in the letter. 


xviii The West Virginia Medical Journal 


Your profession 
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Mail to Administrator: 

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Telephone: 1-304-347-0708 


County Societies 


HARRISON 

Ms. Dexanne B. Clohan. Assistant Director. 
Department of Congressional Relations of the 
American Medical Association in Washington. 
D.C., and Charles R. Lewis of Charleston were 
keynote speakers for the 1983 Health Legisla- 
tion Forum held January 6 in Clarksburg hy the 
Harrison County Medical Society. 

Lewis is Executive Secretary of the State 
Medical Association. 

The forum, which was held at the Sheraton 
Inn, was co-sponsored by the Auxiliary. 

State Senator Gino R. Colombo, Clarksburg, 
and Senator Jean Scott Chace, Weston, and State 
Delegate Percy C. Ashcraft II. Clarksburg, 
participated in the forum. Also present were 
representatives of local hospitals, community 
health and other agencies. 

The forum was attended hy 80. — Caspar Z. 
Barcinas. M. D.. President. 

* * • 

WESTERN 

The Western Medical Society met on January 
18 in Ripley at Jackson General Hospital. 

The guest speaker was Dr. Paul D. Saville of 
Charleston. Clinical Professor of Medicine at 
West Virginia University School of Medicine, 
who spoke on non-steroidal and anti-inflam- 
matory drugs. 

The Society approved the drafting of a letter 
in protest of the announced closing of Spencer 
State Hospital to he sent to Governor John D. 
Rockefeller IV ; Dr. L. Clark Hansbarger, State 
Health Director; Charles R. Lewis, Executive 
Scecretary. State Medical Association, and the 
West Virginia Congressional delegation. — Ali H. 
Morad, M. D., Secretary. 

* # # 

McDowell 

David H. Cleland of Charleston was the guest 
speaker for the meeting of the McDowell County 
Medical Society on January 12 in Welch at 
Stevens Clinic Hospital. 

Cleland is Medical Relations Officer for the 
Disability Determination Service, West Virginia 
Division of \ ocational Rehabilitation. He spoke 
to the Society on the changes in disability 
determination over the past 10 to 20 years, and 
clarified the physician’s role and criteria used to 


determine if a person is disabled. — John S. 
Cook. M. D.. Secretary. 

* # # 

FAYETTE 

Dr. Saghir Mir, Montgomery orthopedic 
surgeon, was the speaker for the meeting of the 
Eavette County Medical Society on January 5 
at Montgomery General Hospital. 

Doctor Mir spoke on “Advances in Ortho- 
pedics.’’ 

The Society approved sending a letter to 
Governor John D. Rockefeller IV asking for 
support of State Medical Association-endorsed 
legislation to limit awards in malpractice suits. — 
Serafino S. Maduedoc, Jr., M. D., Secretary- 
Treasurer. 


EQUIPMENT WANTED 

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and exam room equipment. Also, instru- 
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P. O. Box 1645, Beckley, WV 25801. 


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XXII 


The West Virginia Medical Journal 


Book Review 


STAND TALL! — THE INFORMED 
WOMAN’S GUIDE TO PREVENTING 
OSTEOPOROSIS — Morris Notelovitz, M. D.. 
and Marsha Ware. 208 pages. Price $12.95. 
Triad Publishing Company, Inc., P. 0. Box 
13096. Gainesville, Florida 32604. 1982 

The overtones of the Marine Corps in the 
title of this book are misleading. It is a book 
written to explain what is known about 
osteoporosis and its prevention and management, 
primarily for a lay audience but also for health 
professionals. There are descriptions of bone 
anatomy and physiology, and information on the 
variety of factors that can affect bone resorption 
and deposition. The sites where osteoporosis 
occurs, and why, are covered. There also is in- 
struction on how it can be measured, and there 
are chapters on how to prevent or manage the 
condition together with some illustrative case 
histories. 

At this time it isn't feasible to use the research 
methods that can accurately measure bone 
density on a regular screening basis; to wait 
for the first fractures to occur is much too late. 
What this book has to offer is a discussion of the 
risk factors and the ways that life style can be 
altered to reduce the likelihood of developing 
the condition. From a review of the case reports 
and the way the histories taken are used to direct 
management strategies it is clear that the 
approach has a wide potential nationwide, in 
primary care, for women from the age of 30 up. 

I can therefore heartily recommend this book. 
One of its strengths is its lucid writing and the 
care taken not to overstate what is known or can 
be done. I therefore hope it will be widely and 
well used by primary care practitioners and their 
patients. — R. John C. Pearson, M.B., M.P.H. 


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March, 1983, Vol. 79, No. 3 


xxiii 



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XXIV 


The West Virginia Medical Journal 


The West Virginia Medical Journal 

Vol. 79, No. 4 April, 1983 



Pain And Its Pharmacologic Manipulation 


CHARLES D. PONTE, R.Ph., Pharm.D. 

Assistant Professor of Clinical Pharmacy, School of 
Pharmacy, and Assistant Professor of Family Practice, 
School of Medicine, West Virginia University Medical 
Center, Morgantown 


Pain is a complex, subjective phenomenon and 
difficult to evaluate. The perception of an un- 
pleasant sensation and the emotional reaction to 
the sensation constitute the pain experience. 

The two broad categories of pain, acute and 
chronic, are distinct entities requiring different 
approaches in treatment. Chronic-pain manage- 
ment requires regularly scheduled doses for 
optimal benefit. 

The strong narcotic analgesics should be em- 
ployed when acute or chronic pain is most 
severe and cannot be controlled effectively ivith 
mild analgesics. Recent controlled trials have 
shoivn that neither Brompton s Cocktail nor 
heroin has an advantage over oral morphine 
solution. 

Newer agents may have less abuse or addic- 
tion potential than conventional strong narcotic 
agents. Nalbuphine and butorphanol are as 
effective as morphine and may cause fewer side 
effects than other narcotic analgesics. 

Pain will touch the lives of all individuals at 
some point. It often is regarded as an integral 
part of human existence. Only during the last 
50 years have the types and forms of pain and 
their functions been studied adequately. Despite 
this recent investigation, pain literature still may 
lack scientific content. Many anecdotal reports 
exist, and the subjectivity of pain makes it a 
very difficult area to study. 


There exists no universally accepted system 
of pain measurement. Pain often is perceived 
as evidence of ill health, and can cause feelings 
of anxiety and fear of the unknown. This paper 
will attempt to delineate briefly the nature of 
the pain experience, its forms and its treatment. 

There are generally two components to pain. 1 
First, there is the perception of an unpleasant 
sensation. The perception depends upon the 
type and severity of the pain stimulus. The pain 
experience from a crush injury to a finger will 
undoubtedly be different than that from a pin 
prick to the same finger. The second component 
of pain, and equally important, is the emotional 
reaction. Many cultural, psychological and 
physical factors have input into the reaction. 
Scandinavians and Orientals are considered very 
stoic about pain whereas Mediterranean peoples 
may be more expressive. 

Acute versus Chronic Pain 

The two broad categories of pain, acute and 
chronic, are distinct entities. Their causes may 
be different, requiring different approaches in 
treatment. 1 " 7 

Acute pain may be perceived as nature’s way 
of alerting us that there is something wrong 
with the body. The patient expects that the pain 
will disappear rapidly. The pain also may be 
rationalized as being part of the healing process. 

During acute pain, certain physiological 
parameters change reflexively. Cardiac rate, 
blood pressure, respiration, peripheral blood 
flow, palmar sweating, pupillary diameter and 
muscle tension can all increase. These parameters 
similarly change when anxiety is experienced. 


April, 1983, Vol. 79, No. 4 


69 


Pain > anxiety 


I 

> I pain 


J. 


Anxiety > depression > I anxietv 

t 

Anxiety > hostility > loneliness > | depression 

Depression insomina & eating disturbances 


Chronic pain can be considered a distinct 
disease entity. It cannot be rationalized as part 
of the healing process, and serves no biological 
purpose. It imposes great emotional, physical, 
economic and social demands on the patient, his 
family and society. 2 Because of its discouraging 
and often unrelenting nature, chronic pain often 
creates feelings of helplessness and hopelessness 
in the patient. Because of their preoccupation 
with pain, chronic-pain patients may become 
isolated from their surroundings. The classic 
example is cancer pain. Other causes of chronic 
pain are found in Table 1. 

Cancer patients generally fear dying in pain. 
Most cancer patients do not experience severe 
pain, and most can be treated effectively with 
minimal sedation. 5 

Lipman believes that chronic pain exists in a 
continuum between an aching and agonal phase, 
and that most patients can function with a dull 
background ache. 8 He feels that chronic pain 
comprises a psychological component consisting 
of anxiety and depression in addition to the 
physical component. Both components should 
be treated if adequate symptom control is to be 
achieved. The Figure illustrates the psychologi- 
cal components of pain and their effects on pain 
perception. 

Acute and chronic pain, as noted, require 
different treatment modalities. 9 ' 11 Table 2 


TABLE 1 

Examples of Chronic Pain 


1. 

Cancer 

2. 

Angina pectoris 

3. 

Inflammatory Disease— arthritis 

4. 

Headache 

5. 

Low back pain 

6. 

Phantom limb pain 

7. 

Burn treatment 

8. 

Continued bone marrow aspirations 


From— Dolan M: Am Pharm 


1978; (1812) : 8-13. 

TABLE 2 

Acute Pain 

Analgesic 

Mild 

Aspirin (Acetaminophen) 

Moderate Aspirin plus Codeine 

Severe 

Morphine 

Chronic Pain 

Aching Phase— Non-narcotic analgesics 

Agony Phase— Narcotic analgesics 

Adjunctive 

Therapy— antianxiety agents, phenothiazines, 


antidepressants, corticosteroids, antiemetics 


From— Lipman AG: Am J Hosp Pharm 


1976; 32:270-276. 


From— Lipman AG: Am J Hosp Pharm 
1975; 32:270-276. 

Figure. 

illustrates the prototype analgesics required to 
treat different types of pain. Adjunctive therapy 
has a place in the management of chronic pain 
and will be discussed later. 

Analgesics for Mild-to-Moderate Acute Pain 

Most patients who experience acute pain can 
be managed effectively with drugs such as 
aspirin or aspirin-containing combinations. The 
pain is self-limited and does not require more 
potent narcotic analgesics. Aspirin in combina- 
tion with pentazocine (Talwin) or codeine ' 
oxycodone appears to be more effective than 
aspirin alone, and probably should be the pre- 
ferred combination for moderate acute pain. 12 

Aspirin remains the drug of choice for mild 
acute pain. It also can be effective for mild 
cancer pain. An appropriate starting dose is 650 
mg orally. A higher dose of 975 mg can be used 
safely. Higher doses may increase the duration 
of analgesia but side effects also may be in- 
creased. The average duration of effect is 4.5 
hours. The drug may act peripherally on pain 
receptor mechanisms, block the generation of 
impulses at chemoreceptor sites for pain, or 
interfere with the production of prostaglandins. 
Common side effects include nausea, epigastric 
pain, vomiting, occult GI bleeding and platelet 
inhibition. 

Acetaminophen I Tylenol ) should be used in 
patients who cannot tolerate aspirin, or where 
aspirin is contraindicated. The drug is 
equipotent to aspirin as an analgesic and anti- 
pyretic, and lacks significant gastrointestinal 
side effects. Nephrotoxic and hepatotoxic reac- 
tions are possible with large doses. 

Propoxyphene I Darvon ) is a weak analgesic 
which lacks antipyretic and anti-inflammatory 
properties. Its analgesic activity has not been 
demonstrated consistently in controlled trials. 13 
The drug should not be considered an aspirin 
substitute in cases of aspirin intolerance. This 
drug has significant potential for abuse. 


70 


The West Virginia Medical Journal 


Pentazocine, Codeine 

Pentazocine (Talwin) has an analgesic effect 
similar to aspirin and acetaminophen. The drug 
can produce bizarre central nervous system 
effects including hallucinations. The drug also 
has been associated with a significant addiction 
potential. The drug also may potentiate the 
effects of aspirin. 14 

Codeine, in equianalgesic doses, has effects 
similar to aspirin but lacks significant anti- 
inflammatory activity. It can cause narcotic 
adverse effects including gastrointestinal distress, 
vomiting, sedation, constipation and dizziness. 

The non-steroidal, anti-inflammatory agents 
are more expensive than the usual drugs used 
to treat mild-to-moderate acute pain. They 
should be reserved for use when the usual drugs 
are ineffective, produce undesirable side effects 
or are contraindicated. These agents may pro- 
duce a lower incidence of gastrointestinal side 
effects. A new agent, zomepirac sodium 100 mg 
(Zomax), is approximately equal to codeine 
sulfate 65 mg plus aspirin 650 mg in analgesic 
efficacy. 

The use of analgesic combinations may be 
pharmacologically appropriate. The clinician 
can take advantage of drugs which exhibit 
different mechanisms of action. Aspirin with 
codeine would be a common example. Aspirin- 
phenacetin-caffeine combinations are without 
justification and should not be used. Many 
manufacturers currently are removing phenace- 
tin and caffeine from their products. 

Fixed-dose combinations have the disadvant- 
age of reduced dosage flexibility, and their use 
should be discouraged. Their cost, increased 
adverse reactions and lack of efficacy should 
preclude their routine use. 

Analgesics for Severe Pain 

When acute or chronic pain is most severe 
and cannot be controlled effectively with either 
single or combination mild analgesics, strong 
narcotic analgesics must be used. The individual 
agents vary slightly both in their quantitative 
and qualitative effects, but the pharmacologic 
and therapeutic properties of these drugs are 
quite similar. Unlike the mild analgesics dis- 
cussed, morphine and the other narcotic 
analgesics exhibit increased analgesia with 
higher doses. 

Frequent side effects include gastrointestinal 
intolerance, sedation and vertigo. Gastroin- 
testinal intolerance is often mistaken for a true 
allergic manifestation. A complete history of 


the nature of the reaction is needed for proper 
interpretation. 

Respiratory depression is a serious conse- 
quence of narcotic analgesic use. This effect is 
dose-related and is the same for any narcotic 
at equianalgesic doses. Narcotics act on the 
respiratory center in the brain stem to reduce 
responsiveness to rises in pCCC. Respiratory 
volume is depressed, followed by a decreased 
respiratory rate. However, despite severe 
respiratory depression, the patient may continue 
to breathe via hypoxic drive regulated by the 
carotid and aortic chemoreceptors. Supple- 
mental oxygen support will eliminate the hypoxic 
drive and cause apnea. 1 

Tolerance will develop with continued use of 
these agents. A larger dose will be needed to 
produce a similar effect which smaller doses 
provided initially. Tolerance to adverse reac- 
tions also will develop at the same rate as to the 
analgesic effects. Therefore, increasing the dose 
will not increase the likelihood of developing 
adverse reactions. 

The selection of a particular narcotic 
analgesic should be based upon several pharma- 
cologic factors. These include oral effectiveness, 
duration of action, degree of effect on smooth 
muscle, route of metabolism, and individual 
variation in patient response. 1,3 

Narcotic analgesics are used commonly in 
suboptimal doses. 15 This may occur because of 
fear on the part of prescribers of eliciting 
tolerance and dependence. Patients who ex- 
perience and suffer from physiological pain 
respond differently to narcotics than individuals 
seeking euphoric effects. 

PRN vs. Regularly Scheduled Doses 

Chronic pain management and prevention 
require careful titration of doses of an appropri- 
ate analgesic. It is easier to prevent pain than 
to treat it. Higher doses of analgesics usually 
are required to alleviate pain once it has 
occurred. 

Acute-, severe- or chronic-pain patients may 
be treated with narcotic analgesics on an “as 
needed" basis. Such a practice may mean more 
pain for the patient. He may be hesitant to ask 
for analgesics for fear that this is a sign of a 
weak or bothersome patient. Continual requests 
for pain medication can reinforce addictive 
behavior. Nurses may be hesitant to administer 
“prn" doses for fear of dependency since pain 
is a subjective experience and is difficult to 
assess. 1 “As needed" orders should be dis- 
couraged from routine use when dealing with 


April, 1983, Vol. 79, No. 4 


71 


chronic-pain patients. Regularly scheduled 
doses may be required for severe acute pain 
management for 24 to 48 hours. 

Once the pain has been controlled, narcotic 
requirements will usually lessen, and lower doses 
can be used for maintenance therapy. The 
patient should be started on a moderate dose 
of a narcotic analgesic, and the dose should be 
lowered every several days. The optimal dose 
is between the lowest dose which was associated 
with pain alleviation and the dose where the 
pain returns. Such dosage titration will lower 
the potential for addiction and sedation. 8 

Oral vs. Parenteral Administration 

The oral route of administration is the pre- 
ferred and most convenient way of administering 
medication. 4,14 This obviates the use of 
parenteral dosing with its associated patient 
discomfort and technical mode of administra- 
tion. 

Many narcotics are available in oral dosage 
forms. These agents should never be adminis- 
tered in the same dose as employed parenterally. 
Except for extremely severe pain, oral narcotics 
are effective unless the patient cannot absorb 
oral agents. 

Meperidine ( Demerol ) is an effective oral 
agent when doses of 100-150 mg are adminis- 
tered. Morphine also is an effective oral drug 
when used in appropriate doses ( 60 mg orally = 
10 mg parenterally). 

Dosage Adjustments 

Many chronically ill or older patients may 
experience deteriorating renal or liver function 
either as a consequence of their disease or from 
the aging process. Such patients may require 
dosage adjustments to avoid potential toxicity 
from prescribed medication. Patients should 
have their liver and/or renal function assessed 
periodically to avoid unnecessary problems. 1 

Cocktails 

Brompton’s Mixture originally was used at 
the Brompton Chest Hospital in England in 1952. 
The original formula consisted of morphine, 
cocaine, alcohol, syrup and chloroform water. 
This original formula has undergone many 
modifications by various individuals. The mixture 
now usually contains a narcotic analgesic, a 
CNS stimulant and alcohol in a flavored vehicle. 
A phenothiazine frequently is added as an 
antiemetic. 

Recent controlled trials have shown that 
neither Brompton’s nor heroin has an advantage 


over oral morphine solution. Results of a study 
comparing the Brompton's-type solution and a 
morphine solution indicated no significant dif- 
ference in pain control or in the incidence of 
side effects. 16 It is apparent that none of the 
ingredients in the original formula enhances the 
analgesic effects of the narcotic. 

The routine addition of phenothiazines to a 
narcotic analgesic should be discouraged. 
Narcotic-induced CNS depression, respiratory 
depression and orthostatic hypotension may be 
potentiated. 

Adjunctive Therapy 

A variety of drugs can be used with analgesics 
in the management of pain. These agents have 
particular benefit when used concomitantly in 
the treatment of chronic pain states. 8 

Phenothiazines may provide anxiolytic ac- 
tivity, and are useful in managing nausea which 
frequently occurs with the use of narcotic 
analgesics. Their sedative properties can be 
advantageous to both the patient and clinician. 
Depending upon the drug chosen, the anti- 
cholinergic, sedative, CNS and cardiovascular 
properties may be important considerations for 
a given patient. 

Anticholinergic drugs should be used with 
caution. Side effects including blurred vision, 
dry mouth, urinary retention and constipation 
may be additive to concurrent analgesic medica- 
tion. 

Corticosteroids may have beneficial effects in 
the chronic-pain patient. These drugs may in- 
crease the sense of well-being and appetite. 
They also have proved beneficial in the manage- 
ment of hypercalcemia which is seen in many 
cancer patients. 

Benzodiazepines may enhance night-time seda- 
tion, thereby alleviating the insomnia associated 
with chronic pain. The newer agents .with 
shorter terminal half-lives, or which are not 
metabolized to active compounds, may be pre- 
ferred in chronic-pain patients. 

Tricyclic antidepressants may be beneficial in 
alleviating the reactive depression seen in cancer 
patients. Careful selection of an appropriate 
agent, with particular attention to sedative and 
anti-cholinergic properties, should be encouraged. 

The Problem of Nausea and Vomiting 

Nausea and vomiting frequently occur with 
the use of narcotic analgesics. Narcotics stimu- 
late the chemoreceptor trigger zone in the 
medulla oblongata and enhance vestibular sensi- 
tivity. When phenothiazine antiemetics are not 


72 


The West Virginia Medical Journal 


helpful, an antihistamine can be added to the 
regimen. This may be very useful for the 
ambulatory patient when vestibular sensitivity 
contributes to the nausea. 

Nausea and vomiting also can be caused by 
the disease process and the cancer chemo- 
therapeutic regimens employed. Antiemetics 
should be given prior to the initiation of chemo- 
therapy or radiation therapy in an effort to lessen 
the likelihood or severity of the resultant nausea 
and/or vomiting. 

Newer Agonist-Antagonist Analgesics 

In recent years, newer agents have been 
marketed which have claimed to have less abuse 
or addiction potential than the conventional 
strong narcotic analgesics. These drugs include 
pentazocine, nalbuphine (Nubain) and butor- 
phanol ( Stadol ( . These drugs potentially can 
cause respiratory depression; however, the 
magnitude of the respiratory depression does 
not appear to be enhanced with increasing doses. 

These drugs also carry the potential to elicit 
opiate abstinence syndromes in patients physi- 
cally dependent on narcotic analgesics. Nal- 
buphine is as effective as morphine at the 
appropriate doses. Its onset, peak and duration 
of action are approximately the same as mor- 
phine. Minimal hypotension in post-myocardial 
infarction patients has been noted. The drug 
also produces less nausea and vomiting than 
narcotic analgesics. 1 ' 

Butorphanol appears to be equally as effective 
as morphine, but may be more sedating. The 
cardiovascular effects are uncertain and require 
further study. 18,19 

Conclusions 

Pain is a human experience from which no 
one will escape. Only recently have researchers 
been able to elucidate the complex physical, 
psychological and biochemical interactions 
which make up the pain experience. The 
etiologic factors and type of pain should be 
elucidated before appropriate or adequate treat- 
ment can be initiated. The current armamen- 
tarium consists of many narcotic and non- 
narcotic analgesics. When used properly, they 
are effective and safe drugs. The potential for 
addiction is minimal, especially when narcotic 
analgesics are used in the treatment of chronic 
pain. 

Pain management requires individualized 
treatment. Plans should be formulated which 
employ the most rational agents for a particular 
set of patient circumstances. Through further 
basic research, newer agents will be developed 
which will have advantages over current agents. 


Cheaper, safer and more specific drugs will bring 
an added dimension to the control of pain in 
all of its forms. 

General Prescribing Guidelines for the 
management of acute and chronic pain appear 
at the end of this article. These guidelines will 
offer one method of treating various pain states. 
The recommendation should aid the clinician in 
individualizing therapy for patients. Such an 
approach may alleviate both patient and pre- 
server apprehension. 

Editors Note: Here are the generic drugs 

and trade names ( in parentheses ) to which 
reference is made in this manuscript : penta- 
zocine iTalivin); acetaminophen (Tylenol); 
propoxyphene (Darvon); zomepirac (Zomax); 
meperidine (Demerol) ; nalbuphine (Nubain); 
and butorphanol (Stadol). 

General Prescribing Guidelines 

Acute Pain — Orally Administered Medications 
Situation 1 — Mild Pain 

Aspirin/ Acetaminophen 650 
mg every 4-6 hours. 

Do not exceed 975 mg per 
does ( Little enhanced 
analgesia, increased toxicity). 

Situation 2 — Moderate Pain 

Aspirin/Acetaminophen plus 
25 mg pentazocine every 
4-6 hours 

65 mg codeine every 
4-6 hours 

10 mg oxycodone every 
4-6 hours 

"Oxycodone may carry enhanced addiction 
potential 

Situation 3 — Severe Pain 

Aspirin /Acetaminophen plus 
15 mg methadone 
25 mg morphine 
150-200 mg meperidine 
120 mg codeine 

* Remember 

1. Patients with acute severe pain (i.e., 
postsurgery, orthopedic procedures, ob- 
stetrical procedures etc. ) should receive 
the medication around the clock for at 
least 24 hours. This avoids peaks and 
troughs in pain intensity and maintains 
sustained relief of pain. 

2. These guidelines are to be applied to the 
cancer patient who may have pain of 
varying degree. 


April, 1983, Vol. 79, No. 4 


73 


3. Meperidine should be administered every 
three hours. Schedules indicating ad- 
ministration every four to six hours are 
not appropriate. 

4. Each patient requires careful dosage and 
dosage interval titration. 

5. Exercise caution with methadone to avoid 
cumulative CNS depression, especially in 
the elderly and debilitated. 

6. With continued therapy and tolerance de- 
velopment, dosage may need to be in- 
creased. Use caution but do not hesitate. 

7. Aspirin should be substituted for acetamin- 
ophen in patients who have inflammation 
as part of their pain experience. 

Chronic Pain 

1. Non-tolerant patient: Use usual doses to 
start; excruciating pain or inadequate 
control may require a larger starting dose. 

2. Attempt to reassess patient response 
periodically; proper dosage titration may 
eliminate the need to change medication. 

3. Choose a dose that provides at least four 
hours of relief. No narcotic analgesic has 
a duration of action much longer than 
morphine. Remember, meperidine has the 
shortest duration of action. 

4. Avoid the use of “prn — as needed” 
dosing schedules. If “prn” is selected, 
encourage the patient to ask for medica- 
tion when the pain begins to bother him 
or her, not when the pain is most dis- 
tressing. 

5. Be aware of the oral-parenteral potency 
ratios when contemplating oral doses of 
the narcotic analgesics. Oral dosing is the 
preferred route of administration when 
possible. 

6. Oral administration results in a slower 
onset, lower peak effect and more pro- 
longed duration of action, desirable in the 
treatment of chronic pain. 

7. Inject parenteral analgesics through exist- 
ing intravenous lines when possible. Slow 
infusion (several minutes) is needed when 
the intramuscular doses are used. Avoid 
injecting the analgesics in the infusion 
containers. 

8. Select alternative narcotic analgesics when 
the patient experiences adverse reactions. 


9. Meperidine is less constipating and 
spasmogenic than morphine. Avoid con- 
comitant administration of meperidine 
with mono-amine oxidase inhibitors. Re- 
peated large doses may cause CNS excita- 
tion ( convulsion I . 

Recommendations adapted from: 
Moertel 1980 

Beaver 1980 

(see References) 

References 

1. Gotz V: Control of cancer-related pain and 

emesis. Monograph - Squibb C ontinuing Pharmacy Edu- 
cation 1980 (Third Quarter); 1(2): 1-7. 

2. Dolan M : Pain-reducing the lowest common human 
denominator. Am Pharm 1978; (1812):8-13. 

3. Catalano RB: The medical approach to manage- 
ment of pain caused by cancer. Semin Oncol 1975; 2(4): 
370-390. 

4. Moertel CG: Treatment of cancer pain with orally 
administered medications. JAMA 1980; 244(21):2448- 
2450. 

5. Houde RW : The rational use of narcotic analgesics 
for controlling cancer pain. Drug Ther July, 1980, pp 
41-47. 

6. Beaver WT: Management of cancer pain with 

parenteral medication. JAMA 1980; 244:2653-2656. 

7. Davis JL et al. : Peripheral diabetic neuropathy 

treated with amitriptyline and fluphenazine. JAMA 1977; 
238:2291-2292. 

8. Lipman AG: Drug therapy in terminally ill pa- 

tients. Am J Hosp Pharm 1975; 32:270-276. 

9. Shimm DS et al.: Medical management of chronic 
cancer pain. JAMA 1979; 241:2408-2412. 

10. Beaver WT et al.: Selecting the right analgesic 
for your patient. Patient Care, Feb, 1972, pp 22-45. 

11. O’Neal JT: Managing chronic pain. Am Fam 

Physician 1974; 10(6):75-84. 

12. Moertel CG et al.: Comparative evaluation of 
marketed analgesic drugs. New Engl J Med 1972; 286: 
813-815. 

13. Miller RR et al.: Propoxyphene hydrochloride— 
a critical review. JAMA 1970; 213(6):996-1006. 

14. Moertel CG et al.: Relief of pain by oral medi- 
cations— a controlled evaluation of analgesic combinations. 
JAMA 1974; 229:55-59. 

15. Marks RM, Sachar EJ: Undertreatment of medi- 
cal inpatients with narcotic analgesics. Ann Intern Med 
1973; 78:173-181. 

16. Wescoe G et al.: The Brompton Cocktail no more 
effective than oral narcotic analgesics in chronic pain. 
Hosp Formulary, April, 1980, pp 266-268. 

17. Miller RR: Evaluation of nalbuphine HC1. Am 
J Hosp Pharm 1980; 37:942-949. 

18. Ameer B, Salter FJ: Drug therapy reviews: 

Evaluation of butorphanol tartrate. Am J Hosp Pharm 
1979; 36:1683-1691. 

19. Vandam LD: Butorphanol. New Engl J Med 

1980; 302(7): 38 1-384. 


74 


The West Virginia Medical Journal 


Emergency Thyroidectomy 

ROMEO Y. LIM, M. D. 

Clinical Associate Professor, Department of Otolaryn- 
gology, West Virginia University Medical Center, 
Charleston Division 


Emergency thyroidectomy for severe spon- 
taneous hemorrhage of a goiter has been re- 
ported in various publications. The purpose of 
this paper is to present a case of an enormous 
goiter with tracheomalacia necessitating an 
emergency thyroidectomy in order to establish 
an adequate airway. The highlights of the pro- 
cedure, histological diagnosis and results are 
presented. 

"Progressive thyroid enlargement can lead to 
-*■ obstruction of the airway and swallowing 
passages. 1 This is a case report of a patient who 
developed tracheal obstruction due to a long- 
standing goiter necessitating an emergency 
thyroidectomy and tracheoplastly as a life-saving 
measure. 

Case Report 

A 79-year-old white female patient had an 
enlarging goiter for many years. In recent 
months, she had progressive shortness of breath 
and difficulty swallowing. Pertinent findings 
revealed a well-developed, fairly well-nourished 
patient with marked acute respiratory distress. 
A markedly enlarged thyroid almost filled the 
entire neck and measured approximately 11 x 
10 x 6 cm., compressing the trachea and pushing 
it toward the left (Figure 1 ). Severe inspiratory 
and expiratory stridor could be heard. Indirect 
laryngoscopy was attempted without success. 

Included in the laboratory and x-ray findings 
was a plain x-ray of the neck which showed 
marked deviation of the cervical trachea to the 
left with compression at approximately the 
second and third tracheal rings (Figure 2). 
There was calcification within the mass lesion. 
Barium swallow revealed marked deviation of 
the cervical esophagus to the left (Figure 3). 
Electrocardiogram showed atrial fibrillation. The 
hemoglobin on admission was 14.1 gms.; 
hematocrit. 39.2 per cent. After completion of 
the above studies, the patient was taken to the 
operating room. 

After induction with sodium pentothal and, 
with the use of fluothane (Halothanel, the 
patient was intubated with a #6.5 endotracheal 
tube. The neck was then placed in hyperextended 
position, prepped with Betadine and draped in 


For Tracheal Obstruction 

the usual manner. A transverse collar skin in- 
cision was made. A superior skin flap was 
elevated, subplatysmally. The deep cervical 
fascia was incised at the midline. The left strap 
muscles were retracted laterally to expose the 
less involved side. The left middle thyroid veins 



Figure 1. Enormous goiter with tracheal obstruc- 
tion after intubation at operating table. 



2. Figure 2. Preoperative x-ray of the neck, A-P 
view, with marked deviation and compression of 
the trachea to the left. 


April. 1983, Vol. 79, No. 4 


75 


were identified, clamped, cut and ligated. The 
left recurrent nerve was identified and preserved. 
The left lobe was then completely mobilized after 
transection of its suspensory ligament. 

The dissection was then shifted to the right 
side of the neck. The midportion of the right 
strap muscles was transected. The right middle 
thyroid veins were found to be markedly enlarged 
and engorged. These were clamped, cut and 
ligated. Using sharp and blunt dissection, the 
immense mass was freed from its soft-tissue at- 
tachment. The right inferior thyroid artery was 
finally exposed; this was clamped, cut and ligated 
with 2-0 silk. The right recurrent nerve was 
identified and preserved. The entire mass was 
then removed from its tracheal attachment and 
from its suspensory ligament. The preceding 
technique was based on Lore’s method of 
thyroidectomy. 2 

Sternothyroid Muscle Patch 

On removal of the entire specimen, it was 
noted that the right anterior lateral wall of the 
first to the third tracheal rings had been softened 
and compressed. A sternothyroid muscle patch 
was used to cover the denuded tracheal rings. 3 
A tracheostomy was then performed by removing 
an anterior segment of the fourth tracheal ring. 



Figure 3. Preoperative barium swallow showing 
marked deviation of the esophagus to the left. 


A #6 tracheostomy tube f Shiley ) was inserted 
into the tracheostomy opening, and the anes- 
thetic agent was continued through this tube. 
The wound was irrigated with hydrogen peroxide 
solution and saline solution. Topical thrombin 
solution was instilled into the wound cavity. A 
Hemovac drain was inserted and brought out 
inferiorly through the skin. The right strap 
muscles were approximated. The skin incision 
was closed with skin clips in one layer, and a 
vertical skin incision was made at the midportion 
of the skin flap for the tracheostomy. A spray 
( Aeroplast I dressing was applied. The approxi- 
mate blood loss was 600 cc.; consequently, a unit 
of packed cells was transfused. The patient 
tolerated the procedure well and left the operat- 
ing table in satisfactory condition. Digoxin 
I Lanoxin ) was administered by the internist for 
the atrial fibrillation. 

The pathology report disclosed a 450-gram 
multinodular thyroid gland with acute infarction 
and an extensive hematoma measuring 8.5 x 8.5 
x 7 cm. ( Figure 4 ). The infareted large thyroid 
nodule showed gross outlines of thyroid follicles 
with a thickened outer capsule. There was no 
carcinoma in this nodule. The noninfarcted 
adjacent thyroid tissue showed multiple smaller 
nodules, which were follicular carcinoma. Around 
the tumor nodules there was evidence of capsular 
and small-vessel invasion. 



Figure 4. Goiter weighing 450 grams with asso 
ciated follicular carcinoma. 


76 


The West Virginia Medical Journal 




Figure 5. Postoperative A-P x-ray of the neck 
with tracheostomy tube in place and an improved 
tracheal patency. 


Hospital Course 

The postoperative recovery of the patient was 
uneventful. She was fully alert and was swallow- 
ing well the day after the operation. She was 
placed on levothyroxine 0.2 mg. (Synthroid) 
daily, and was on digoxin 0.125 mg. (Lanoxin) 
daily. The calcium level dropped to 7.2 mg/DL 
on the seventh postoperative day; however, on 
discharge 12 days later, the calcium level was 
8.6 mg/DL. A tracheal plug was inserted on 
the tenth postoperative day: this was tolerated 
by the patient. After decannulation she was dis- 
charged on the twelfth postoperative day. Post- 


operative barium swallow showed the restoration 
of the cervical esophagus and trachea to their 
normal positions. The tracheal lumen was 
adequately restored (Figure 5). 

Discussion 

Gradual enlargements of a goiter can lead to 
obstruction of the trachea or esophagus. In most 
cases of respiratory obstruction, symptoms are 
long-standing, and the degree of obstruction 
progresses very slowly so that patients can and 
do delay seeking medical help for a long period 
of time. Emergency thyroidectomy has been 
performed on spontaneous hemorrhage of a 
retrosternal goiter. 4 Sudden hemorrhage of a 
goiter, caused by injury, has been reported fol- 
lowing attempts at strangulation during a family 
quarrel. 4 

Summary 

A case of follicular carcinoma in an enormous 
goiter with severe tracheal and esophageal com- 
pression is presented. An emergency thy- 
roidectomy with primary repair of the tracheo- 
malacia using a muscle patch is described. 

Editor's Note: Here are the generic drugs 

and trade names {in parentheses ) to which 
reference is made in this manuscript: digoxin 

[Lanoxin ) , levothyroxine ( Synthroid ) and fluo- 
thane ( Halothane) 

References 

1. Calcaterra TC, Maceri DR: Aerodigestive dys- 

function secondary to thvroid tumors. Laryngoscope 
1981; 91:701-707. 

2. Lore JM: Atlas of Head and Neck Surgery, ed 2, 
Philadelphia, WB Saunders Co, 1973, p 618. 

3. Montgomery WW: Surgery of the Upper Respira- 
tory System, vol 2, Philadelphia, Lea and Febiger, 1973, 
p 421. 

4. Wade JSH: Respiratory obstruction in thyroid 

surgery. Ann R Coll Surg Engl 1980; 62:17-24. 


April, 1983, Vol. 79, No. 4 


77 



From the Wes! Virginia University 
Medical Center 

Edited By 

Irma II. Ullrich, M. D. 

Associate Professor of Medicine 

The Noninvasive Diagnosis Of Coronary Artery Disease 


Discussant: 

ANTHONY P. MORISE, M. D. 

Assistant Professor of Medicine , Department of 
Medicine ( Section of Cardiology ) 


When coronary angiography is not absolutely 
indicated, a noninvasive approach to the 
diagnosis of coronary artery disease is often 
desirable. However, because of the inherent 
imperfections of noninvasive testing, the results 
will always produce a relative uncertainty con- 
cerning the diagnosis, especially in patients with 
atypical symptoms. 

This paper ivill discuss a format for approach- 
ing patients with suspected coronary artery 
disease by using noninvasive testing modalities. 
The discussion will emphasize the application of 
Bayesian analysis to both the interpretation of 
test results and the selection of the test or tests 
that will generate the most information in a cost- 
effective manner. Also included with this dis- 
cussion will be comments on the criticisms and 
limitations as well as the future applications of 
the Bayesian approach. 

A ll clinicians who are involved in evaluating 
patients suspected of having coronary artery 
disease (CAD) employ their skills of history- 
taking and physical examination as the initial 
step. Based upon these skills, we have all seen 
patients whom we thought had either a high 
or low probability of having CAD, e.g., a patient 
with typical angina pectoris with several strong 
risk factors. These clinical hunches would many 
times he put to the test by comparing them to 
the accepted “gold standard,” in this case 


coronary angiography, and confirmation of our 
hunches would undoubtedly secure our faith in 
our clinical diagnostic abilities. 

There often are patients, however, who defy 
categorization on clinical grounds and engender 
a relative uncertainty concerning their diag- 
nosis, e.g., those with atypical symptoms. Diag- 
nostic studies are not usually gratifying in these 
patients, and one’s faith in certain clinical 
markers often is shaken considerably. Over the 
past 10-15 years, considerable effort has been 
put forth to explain the reason for these diag- 
nostic pitfalls and to provide a practical non- 
invasive method for avoiding them. Jt is, there- 
fore, the intent of this discussion to elaborate 
upon these two points in respect to the non- 
invasive approach to the diagnosis of CAD. 

Noninvasive is an unfortunate adjective 
because several of the noninvasive tests are not 
strictly without penetration of the skin. Never- 
theless, the term is uniformly understood by all 
to imply a test that is noncatheter or nonsurgi- 
cal by nature, thereby carrying less risk, in- 
convenience and cost. 

Coronary angiography, which is the current 
invasive standard for the comparison and evalu- 
ation of these noninvasive studies, is a useful 
clinical tool, but is by no means perfect, as has 
been pointed out by Roberts et aid It is only 
the angiographic delineation of coronary luminal 
anatomy with often little to say about the effect 
of that anatomy on the perfusion to the 
myocardium downstream. In considering the 
fact that most, but not all, of the noninvasive 
studies investigate a physiologic aspect of the 


78 


The West Virginia Medical Journal 


coronary system, it is not a surprising fact that 
noninvasive studies will be less than perfect in 
predicting the coronary, i.e., luminal, anatomy. 
It is the classic case of comparing apples and 
oranges, which are obviously quite different, but 
both classified as fruit. Luminal anatomy and 
ischemia are both expressions of coronary 
atherosclerosis, but they are entirely different 
categories of expression. 

Add to this the fact that the hallmark for the 
diagnosis of CAD is usually a qualitative as- 
sessment, and the problems of comparison are 
magnified further. The percentage of reduction 
in the cross-sectional area of the coronary artery 
that leads to a measurable physiologic change 
is reasonably well defined, but the ability to 
measure visually that percentage of reduction 
is far from perfect. Granted, an apparent lesion 
of greater than 70 per cent, more often than not. 
will be physiologically significant, but what 
about the lesions that “look like” 40-60 per cent? 
Also, positive noninvasive study results may be 
indicating other types of heart disease that are 
not seen by the angiogram. Clearly, the “gold 
standard needs improvement. 

The list of noninvasive testing currently or 
soon to be available is noted in the Table. All, 
with the exception of fluoroscopy, examine the 
effects of ischemia on some aspect of coronary 
or ventricular physiology. These aspects also 
are noted in the Table. Indeed, it is not my 
intent to discuss the relative advantages of each 
modality, but rather to provide a format for 
interpreting the results of these tests and as- 
sessing their utility in the light of their well- 
documented imperfections. 

Predictive Accuracy 

Before discussing the format for analysis, I 
would like to present some background infor- 
mation. First, the accuracy of diagnostic tests 
is usually indicated by the terms, sensitivity and 


specificity. 1 2 These terms define the ability to 
detect patients with and without disease, 
respectively. These quantities say nothing as to 
the probability of disease in an individual. That 
particular quantity known as predictive accuracy 
I PA ) or value, therefore, comments on the test 
result rather than the test itself. It is a quanti- 
tative expression of the likelihood that a given 
test result indicates the presence of disease. In 
general, it is a much more clinically useful value 
than sensitivity or specificity. 

These three values are all dependent upon 
how a positive or negative test result is defined 
and. as expected, the measured values will be 
different for each test result. Herein lies the 
fallacy of the conventional, but oversimplified, 
classification of test results as either positive 
or negative. Rifkin and Hood demonstrated 
that for exercise stress testing there is a con- 
tinuum of risk depending upon the absolute 
amount of ST segment depression. 3 4 Virtually 
all of the nine basic tests available have either 
a wide range of tests results (as for exercise 
ECG ) or 3-4 discrete test results ( as for exercise 
radionuclide angiography). Therefore, these 
multiple possible test results, rather than pro- 
viding a definitive answer as to the presence 
or absence of CAD, provide a probability state- 
ment concerning the likelihood of disease. 

Effect of Disease Prevalence 

Second, a number of studies have shown that 
the PA of a test result is dependent upon the 
chance of the patient having CAD before the 
test is administered. 3 ' 5 6 7 8 9 10 This pretest risk also 
is known as prevalence or pretest likelihood, and 
is the main ingredient in the format called 
“conditional probability analysis,” which will be 
discussed shortly. Referring to large groups, 
the prevalence represents the percentage of the 
population that is affected by CAD at any given 
time. This principle of dependence of PA on 


TABLE 

Noninvasive Testing Modalities and Aspects of Cardiac Anatomy and/or Physiology Examined 


1. Exercise Electrocardiography 0 

2. Exercise Thallium Scintigraphy 0 

3. Exercise Radionuclide Angiography 0 

4. Exercise Cardiokymography 

5. Exercise Echocardiography 

6. Coronary Fluoroscopy 0 

7. Positron Emission Tomography 

8. Nuclear Magnetic Resonance 

9. CAT Scanning 

10. Digital Subtraction Technique 


Electrical Repolarization 
Perfusion 

Myocardial Function 
Myocardial Function 
Myocardial Function 
Calcification of Arteries 
Myocardial Function, Perfusion, Metabolism 
Myocardial Function, Perfusion, Metabolism 
Myocardial Function, Perfusion 
Myocardial Function 


° Most-available tests with the best data to generate PAs. 

April, 1983, Vol. 79, No. 4 


79 


prevalence or pretest likelihood is more famil- 
iarly known as Bayes’ Theorem. There has been 
much discussion of this theorem in the medical 
literature over the last 20 years, and its mention 
is increasing exponentially. 6 " 8 

The prevalence for CAD has been determined 
for several clinical classifications from pooled 
autopsies according to age, sex and chest-pain 
symptomatology. 9 Diamond and Forrester 10 also 
have developed a computer program for deter- 
mining prevalence considering these variables 
as well as coronary risk factors. This same group 
also has shown that the prevalence of disease 
for asymptomatic patients ( which is much lower 
than for symptomatic patients) can be approxi- 
mated from the Framingham study data pre- 
sented in the Coronary Risk Handbook. 9 

In addition to Bayes’ Theorem, there also is 
a formula bearing that name which allows for 
the calculation of PA given the prevalence or 
pretest risks and the sensitivity and specificity 
for each test result.' Unfortunately, all of the 
tests have not been investigated sufficiently to 
establish sensitivity and specificity data, but 
Forrester et al. have presented the sensitivity 
and specificity results for pooled studies for five 
noninvasive tests with data on virtually all of 
the possible normal and abnormal results for 
each of these tests. 9,11 

Conditional Probability Analysis 

With sensitivity, specificity and prevalence in 
hand, one next can begin to address the question 
of interpreting test results. This process is 
termed “conditional probability analysis” be- 
cause the originally-believed probability is modi- 
fied by the conditions of an observation, in this 
case, a test result. Clinicians intuitively employ 
probability analysis in making diagnostic de- 
cisions, but, as noted earlier, not without notice- 
able imperfection or uncertainty. 

Baves’ formula allows us to take a test’s 
sensitivity and specificity and the patient’s pre- 
test likelihood for CAD, and calculate a post- 
test likelihood or PA for disease. If we take a 
spectrum of prevalence ranging from 0-100 per 
cent and determine the PA for each point, we 
can generate a series of PAs which will form 
a curve with a parabolic configuration. 9 Using 
these curves, the PA for a test result can be 
determined by simply knowing the pretest risk 
or prevalence. These curves, as w^ell as tabular 
data, can be seen in a number of excellent review 
articles on this subject. 2,9,12,13 Data for exercise 
electrocardiography, thallium exercise testing, 
exercise radionuclide angiography, and coronary 
cinefluoroscopy, which make the determination 


of PA or post-test likelihood very easy, 11 recently 
have been published. In addition, there is a 
computer software program available which will 
determine the PA for five noninvasive tests. 10 

Two Interpretations 

Now assuming one takes the time to determine 
the likelihood of disease before or after a test, 
what then does one do with this value? Clinically 
speaking, there are two w r ays of interpreting the 
probability. The first deals with the likelihood 
of disease in the patient based upon an achieved 
test result. This is a diagnostic interpretation. 9 
Concerning this interpretation of the PA, 
Diamond et al. 14 have suggested from the tech- 
niques of information theory that a PA of less 
than 10 per cent or greater than 90 per cent 
should be the diagnostic end points for non- 
invasive testing. In other words, if a patient’s 
PA is in those ranges, further noninvasive testing 
for diagnostic purposes is not warranted except 
in very special circumstances. 

These diagnostic end points have not been 
completely validated yet but, clearly, further 
noninvasive studies will only serve either to 
confirm what is already strongly supported by 
the evaluation to that point, or cloud the picture 
considerably by moving the PA between 10 and 
90 per cent. Ideally, of course, a physician 
should select a threshold above which one action 
will be taken and below 1 which another action 
w ill be taken, e.g., consider having CAD and treat 
appropriately or doing another diagnostic test. 

The second type of interpretation deals with 
predicting the discriminative function of a test 
yet to be performed. 12 The major difference 
between the two interpretations rests upon 
whether the likelihood is determined before or 
after the test is performed. Although it is pos- 
sible to render an interpretation of an achieved 
test result by finding the PA for that result, it 
also is possible to see what the PA will be if the 
patient generates a proposed result. 14 For 
example, given a prevalence of 50 per cent in 
a particular patient, one can determine whether 
a negative exercise electrocardiographic result 
can, for practical purposes, exclude CAD, i.e., 
reduce the likelihood to a very small number. 
While in many instances this will be helpful, 
the real impact of this type of interpretation will 
be felt when one is considering the more ex- 
pensive noninvasive studies such as thallium 
scintigraphy. 1 ’ The important principle here is 
avoidance of unnecessary or insufficiently dis- 
criminative testing. If coronary angiography 
were a quick and inexpensive test with no risks, 
there would be less justification for noninvasive 


30 


The West Virginia Medical Journal 


studies. However, since this is not so, avoidance 
of the cost and risk of angiography is a major 
driving force behind noninvasive testing. But 
if we have utilized a number of expensive non- 
invasive studies arbitrarily, we already may have 
negated one of the advantages of noninvasive 
testing. Therefore, the take-home message is the 
following: let us try to avoid coronary 

angiography if w r e can, but not at the expense 
of spending more to avoid the angiogram than 
it would have cost to perform it. 

Practical Examples 

Currently, only four or five of the noninvasive 
studies in the Table have been evaluated to the 
extent that tables for PA determinations are 
available. 911 It should not be our intent to use 
all of the testing modalities in a patient, but to 
select the one or two which will yield the most 
information in a cost-effective manner. 15 I 
believe the Bayesian format attempts to provide 
this cost-effective selection process. Although 
far from its final form, it is practical in its 
present state and, from studies done thus far. 
it would appear that the major use of single or 
multiple noninvasive studies is for the assessment 
of the group of patients with a prevalence for 
CAD between 10 and 90 per cent. 12,14 

Further subdivision of this large group leads 
to branching logic trees that are far more con- 
fusing than clarifying. Let me instead present 
some practical examples to demonstrate the use- 
fulness of this format: 

1. A 55-year-old man with typical angina 
pectoris had a prevalence of 92 per cent. An 
exercise stress test will be performed and. if the 
test is positive, the increase in diagnostic 
accuracy will be marginal (four to 96 per cent) 
and will confirm what already was evident from 
the history. If the test is negative, the PA will 
be 73 per cent. Therefore, CAD certainly will 
not be excluded. Therefore, the exercise test will 
not really be useful diagnostically, although it 
may be useful for other purposes. Furthermore, 
it is not likely that subsequent noninvasive test- 
ing will help to exclude CAD with enough 
certainty to warrant its expense. This is simply 
because of the fact that in this case no non- 
invasive study will lower the PA enough to say 
that angiography is not needed to exclude the 
diagnosis. 

2. If the same man had atypical angina, his 
prevalence would fall to 59 per cent, and the 
negative stress test would yield a PA of 25 per 
cent. What you do at this point depends on your 
philosophy of practice, but what is important 


to understand is that there is still a one-in-four 
chance of CAD. One further noninvasive study 
(Thallium) would be very discriminative. If 
negative, the PA will be six per cent; if positive, 
79 per cent. This would be enough discrimina- 
tion to make a reasonable decision. In general, 
the probability information, although not defini- 
tive, will be sufficient to justify a management 
decision. Of course, if absolute certainty is 
desired, coronary angiography is the only re- 
course. 

3. Let us suppose a 45-year-old woman pre- 
sents with atypical angina yielding a prevalence 
of 13 per cent, and her stress test yielding one 
and one half mm of horizontal ST segment 
depression, raises her PA to 39 per cent. A 
negative Thallium scan would lower it to 10 
per cent whereas a negative radionuclide 
angiogram would lower it to two per cent. If 
one had obtained coronary fluoroscopy after the 
stress testing and obtained a negative result. 
Thallium would then lower the PA to 5 per cent. 

4. One final example is a 45-year-old 
asymptomatic man who desires an exercise test 
before starting an exercise program. Without 
considering risk factors, his prevalence is six 
per cent. By using the Coronary Risk Hand- 
book. 16 one could modify his pretest likelihood 
up or down to, for example, 10 per cent. He 
then exercises, producing two mm of ST segment 
depression yielding a PA of 52 per cent. How 
one handles him once again depends on one’s 
philosophy of practice, but a negative radionu- 
clide angiogram would lower the PA to four per 
cent, and a negative Thallium study would lower 
it only to 16 per cent. It should be clear to the 
reader that if one waits until after the test is 
performed to determine the PAs, one may find 
that the effort and expense were wasted. There- 
fore, one can evaluate whether a single or a 
series of noninvasive studies will be useful by 
looking at the extremes of possible test results. 
I should note that the order of test sequencing 
does not influence the final likelihood. This 
would allow one to modify considerably and 
individualize a diagnostic approach. 

Test Limitations 

Thus far, 1 have touted the merits of this 
approach but, to be fair, I should mention and 
comment upon the criticism it has received and 
its limitations. In this respect, Feinstein has been 
the most outspoken, considering the application 
of Bayes’ Theorem to clinical medicine. 17 His 
objections have been theoretical, for the most 
part, and while it is true that not all areas of 
medicine are appropriate for this type of 


April, 1983, Vol. 79, No. 4 


81 


analysis, the real merit of any diagnostic 
approach ultimately should be based upon its 
success and not its theoretical limitations. 

Statistical independence of test results means 
that the results of different tests are based on 
end points that are independent of one another. 
For example, two tests should not be both 
looking at the same parameter such as ventri- 
cular function. Since Bayes’ Theorem requires 
adherence to this principle, serial application of 
tests that are not independent could invalidate 
the results. However, it has been demonstrated 
that the influence of this principle is not signifi- 
cant as long as the number of tests sequentially 
employed is small. 18 This is true for the 
approach presented here. Likewise, it would 
appear that the most easily available tests 
(starred in the Table) are independent as the 
endpoints are all different ( repolarization, per- 
fusion. ventricular function, and artery calcifica- 
tion ) , 19 

Feinstein has stated that this decision process 
does not even closely resemble the real clinical 
situation because of the complexity of the usual 
situation and the subjective nature of the data. 1. 
Also, because of the continued vagueness of the 
PA. he states that clinicians usually order the 
most suitable tests to rule in or rule out disease. 
He states that if there is uncertainty, one should 
get more data. What he fails to realize is that 
in clinical medicine the most cost-effective test 
should be ordered, and not always the most suit- 
able one, i.e., coronary angiography. However, 
with so many noninvasive tests available, the 
practicing physician is often at odds with select- 
ing the most cost-effective study for the indi- 
vidual patient. 

Bayesian Analysis Could Help 

Clearly, a procedure’s cost-effectiveness is 
greatly dependent upon how often it is appropri- 
ately ordered. 15 Even highly sensitive and 
specific tests may not lead to cost savings if they 
are ordered inappropriately for patients who will 
not experience a change in management result- 
ing from the test. Procedures with greater risks 
and inconvenience such as coronary angiography 
are more likely to be appropriately ordered than 
are noninvasive studies. This inappropriate 
ordering only serves to promote overutilization 
of the study which, in turn, tends to reduce its 
cost-effectiveness. This principle was demon- 
strated in a study by Feinstein himself. 20 There- 
fore. Bayesian analysis could be just the method 
for improving cost-effectiveness by using the 
uncertainty inherent in all of these studies to 
our best advantage. 


Next, Feinstein stated in f977 that he knew 
of no published work that demonstrated the 
successful application of Bayes’ method to clini- 
cal medicine. 1 ' This was a valid criticism then, 
and I would certainly agree that any new 
diagnostic method needs to be compared to the 
current standards to see if diagnostic accuracy, 
patient care and cost-effectiveness are really 
improved. 

Since 1977, several papers comparing the 
clinical to the calculated likelihood of disease 
have been published. 9,14,21,22 Hlatky et al. 22 
have published data indicating that probability 
calculations considering only age. sex, chest 
pain, and exercise EGG response were at least 
as good as the cardiologists assessment and. in 
a few instances, better. These probability 
calculations were improved upon when a com- 
puter program involving more variables was in- 
volved. 10,22 Indeed, there is a lot to be learned 
concerning these techniques, but to say that their 
accuracy is unproved is no longer true. In all 
fairness, I have not seen any comment by 
Feinstein concerning these subsequent studies. 
The ultimate test will be to assess their cost- 
effectiveness in some sort of randomized, pros- 
pective clinical trial. 

Pooled versus Local Data 

One area of difficulty that is not easy to 
deal with is the universally assumed values for 
sensitivity, specificity and prevalence. The 
sensitivitv and specificity data quoted in the 
literature 911 are derived from pooled data from 
many sources and may not lie the values that 
practitioners are working with in their local 
institutions. If the determination of the local 
sensitivity and specificity is possible, this should 
be done, but where this cannot be done, the 
published values should be utilized as the best 
and only available figures. Also, prevalence can 
vary from area to area with the published figures 
representing only a pooled average. 9 Obviously, 
the validation of the pooled prevalence data in 
a number of geographical regions would help 
to weaken this criticism. 

In addition to the presence or absence of 
disease, noninvasive tests are also ordered, often 
simultaneously, to obtain other information, e.g., 
location and severity of disease. Thus far. 
standard Bayesian analysis does not consider 
these other questions, but once again. Diamond 
et al. have demonstrated a computer-assisted 
approach which does address this important 
question. 10 Further applications to these ques- 
tions should be forthcoming. 


82 


The West Virginia Medical Journal 


The exercise test long has been maligned for 
its excessively high false negative rate. 23 Mostly, 
this is due to the naive consideration of only ST 
segment depression in the test result. When 
a multivariate approach is used, much better 
accuracy is obtained. 24 Santinga et al. also have 
incorporated other stress test variables into their 
Bayesian analysis. 23 Validation of these refine- 
ments as well as others that use a multivariate 
approach certainly will be necessary in order to 
maximize the diagnostic capability of each test. 

Unfortunately, as long as coronary an- 
giography is the "gold standard,” one limitation 
will always be present. For those who prefer a 
yes or no answer, noninvasive testing virtually 
will never be satisfactory. If one cannot deal 
with uncertainty, as some have made clear, then 
this type of analysis will be only an academic 
exercise with no real clinical application. On 
the other hand, one also should not be misled 
into thinking that this analysis is a panacea that 
will make gray-area decisions black or white. 
It is intended as a clinical tool or guide to 
complement the other clinical skills and tools, 
and assist in selecting and interpreting a test or 
tests so that the patient will be presented with 
the least amount of uncertainty concerning a 
diagnosis. 

The appearance of Bayes’ Theorem in the 
literature is likely to increase as long as there 
are those who are comfortable with probabilities 
in place of discrete yes or no answers. As to its 
true cost-effectiveness, I look forward to studies 
addressing this very important question. 

References 

1. Arnett EN, Isner JM, Redwood DR, Kent KM, 

Baker WP, Ackerstein H, Roberts WC: Coronary artery 
narrowing in coronary heart disease: Comparison of 

cineangiographic and necropsy findings. Ann Intern Med 
1979; 91:350-356. 

2. Griner PF, Mayewski RJ, Mushlin AI, Greenland 

P: Selection and interpretation of diagnostic tests and 

procedures. Ann Intern Med 1981; 94:559-563. 

3. Rifkin RD, Hood WB : Bayesian analysis of electro- 
cardiographic exercise stress testing. N Engl J Med 1977; 
297:681-686. 

4. Weiner DA, Ryan TJ, McCabe CH, Kennedy JW, 
Schloss M, Tristani F, Chaitman BR, Fisher LD: Cor- 
relations among history of angina, ST-segment response, 
and prevalence of coronary-artery disease in the Coronary 
Arterv Surgerv Studv (CASS). N Engl J Med 1979; 301: 
230-235. 

5. Detry JR, Kapita BM, Cosyns J, Sottiaux B, 
Brasseur LA, Rousseau MF : Diagnostic value of history 
and maximal exercise electrocardiography in men and 
women suspected of coronary heart disease. Circulation 
1977; 56:756-761. 


6. Llewelyn DEH, Anderson J: The historical de- 

velopment of the concepts of diagnosis and prognosis 
and their relationship to probabilistic inference. Med Inf 
1980; 5:267-280. 

7. Brown GW: Bayes’ Formula— Conditional probabil- 
ity and clinical medicine. Am ] Dis Child 1981; 135: 
1125-1129. 

8. Wagner HN: Bayes’ Theorem— An idea whose 

time has come? Am J Cardiol 1982; 49:875-877. 

9. Diamond GA, Forrester JS: Analysis of probability 
as an aid in the clinical diagnosis of coronary-artery 
disease. N Engl ] Med 1979; 300:1350-1358. 

10. Diamond GA, Staniloff HM, Forrester JS, Pollack 

BH, Swan HJC: Computer assisted diagnosis in the 

noninvasive evaluation of patients with suspected cor- 
onary artery disease. J Am Coll Cardiol 1983; 1:445-455. 

11. Staniloff HM, Diamond GA, Freeman MR, Ber- 
man DS, Forrester JS: Simplified application of Bayesian 
Analysis to multiple cardiologic tests. Clin Cardiol 1982; 
5:630-636. 

12. Epstein SE : Implications of probability analysis 
on the strategy used for noninvasive detection of coronary 1 
artery disease. Am J Cardiol 1980; 46:491-499. 

13. Hamilton GW, Trobough GB, Ritchie JL, Gould 

KL, DeRouen TA, Williams DL: Myocardial imaging 
with Thallium 201: An analysis of clinical usefulness 

based on Bayes’ Theorem. Semin Nucl Med 1978; 8:358- 
364. 

14. Diamond GA, Forrester JS, Hirsch M, Staniloff 
HM, Vas R, Berman DS, Swan HJC: Application of 
conditional probability analysis to the clinical diagnosis 
of coronary artery disease. J Clin Invest 1980; 65:1210- 
1221 . 

15. Goldman L, Adams JB: Cost effectiveness in 

medical decision making: Cardiac nuclear medicine and 
exercise electrocardiograms. Cardiovasc Rev Rep 1981; 
2:45-53. 

16. Coronary Risk Handbook, New York, American 
Heart Association, 1973. 

17. Feinstein AR: Clinical biostatistics. XXXIX. The 
haze of Bayes’— The aerial palaces of decision analysis, 
and the computerized ouija board. Clin Pharmacol Ther 
1977; 21:482-496. 

18. Fryback DG: Bayes’ Theorem and conditional 

nonindependence of data in medical diagnosis. Comp 
Riomed Res 1978; 11:423-434. 

19. Charuzi Y, Diamond GA. Pichler M, Waxman A, 
Vas R, Silverberg RA, Berman DS, Forrester JS: Analy- 
sis of multiple noninvasive test procedures for the diagno- 
sis of coronary artery disease. Clin Cardiol 1981; 4:67-74. 

20. Goldman L. Feinstein AR. Batsford WP: Order- 
ing patterns and clinical impact of cardiovascular nuclear 
medicine procedures. Circulation 1980; 62:680-687. 

21. Diamond GA, Forrester JS: Probability of CAD 
(letter). Circulation 1982; 65:641-42. 

22. Hlatky M, Botviniek E, Brundage B: Diagnostic 
accuracy of cardiologists compared with probability cal- 
culations using Bayes’ Rule. Am J Cardiol 1982; 49: 
1927-1931. 

23. Epstein SE: Limitations of electrocardiographic 
exercise testing. N Engl ] Med 1979; 301:264-265. 

24. Berman JL. Wynn J, Cohn PF : A multivariate 
approach for interpreting treadmill exercise tests in 
coronary artery disease. Circulation 1978; 58:505-512. 

25. Santinga JT, Flora J, Maple R, Brymer JF, Pitt B: 
The determination of the post-test likelihood for coronary 
disease using Bayes’ Theorem. J Electrocardiol 1982; 
15:61-68. 


April. 1983. Vol. 79, No. 4 


83 


c/£ meAAage fcom . . . 



*Jhe PzeAident 

ETHICS, MEDICINE AND SOCIETY 


jn all the hubbub, clamor and furor of the current 

debate about “cost containment,” one other con- 
cept of significance seems to be emerging and quite 
possibly changing. This is the broad concept called 
ethics. We are all aware of the impact of ethical 
considerations in our lives, but these generally have 
been somewhat esoteric, and have not received 
widespread publicity or public attention. Increasing 
demand for unlimited, high-quality medical care 
in the face of finite resources may force us all to 
re-examine our beliefs about these difficult concepts 
which eventually will confront us all, physicians or 
laymen alike. 

Of course, physicians, since the dawn of time, 
have been subjected to different creeds of ethics 
developed for the benefit of the patient, from the 
Oath of Hippocrates down through the American 
Medical Association’s Principles of Medical Ethics. 
Physicians are not unfamiliar with the problems 
involved in making the choices and decisions re- 
quired in the care of our patients, but these choices 
and decisions now apparently are spreading to in- 
volve a broader segment of society. Ethical 
dilemmas such as appropriate care of an in- 
competent patient, possible rationing of medical 
care due to increasing demand and decreasing 
resources, or the advisability of withholding treat- 
ment in hopeless situations, increasingly are be- 
coming more prominent and publicized. These 
ethical and moral decisions have been made by 
physicians from time immemorial but there seems 
to be a growing trend to extend this responsibility. 

The question, it seems to me, is becoming who 
has the responsibility or obligation to make these 
decisions? In a recent study from California, it was 
estimated that approximately 20 per cent of the 
resources of a group of hospitals was expended to 
care for people whose prognosis was less than a 
year. In the Medicare program, around .5 per cent 
of the patients, those with end-stage renal disease, 
consume almost 10 per cent of the funds. Is it 
ethical to expend so much of society’s resources on 
a limited number of people or on those with very 


little chance of long-term survival? If so, why? 
And, if not, who is to make that decision? Is it 
ethical to deny expensive and potentially painful 
care to a baby born with severe birth defects, or 
is it more ethical to expend all of our energy, 
resources, and technology to prolong this life? Do 
we place a value in dollars and cents on an indi- 
vidual life? And, if so, who determines that value? 
Do ethical considerations come down in the end to 
a matter of money? If society as a whole pays the 
bill, who has the right to dictate to an individual 
what his or her choices must be? 

These are indeed difficult questions. And for me, 
at least, the answers are not clear. In the practice 
of Medicine, however, in this day and age, there 
seems to be a requirement for answers to these 
possibly unanswerable questions. How do we 
approach this? Is it the duty of our elected officials 
to provide answers to these questions? If so, has 
the Legislature understood and accepted this 
awesome responsibility? Or, is it the province of 
the courts to make these determinations? Will our 
already overburdened legal system be able to 
respond to the split-second decisions that are some- 
times required? Is it able to accept this responsi- 
bility in a timely fashion? 

These are but a few of the many questions that 
arise when ethical considerations meet harsh 
economic realities. Attempting to answer these 
questions will challenge us to re-evaluate our own 
beliefs and behavior as well as those of others. I 
feel it is the responsibility of our profession, as on 
so many other occasions, again to take the lead in 
evaluating these questions and trying to resolve 
them. If we do not, we can rest assured others will. 



Harry Shannon, M. D., President 
West Virginia State Medical Association 


84 


Thf. West Virginia Medical Journal 


The West Virginia Tledical Journal 

Editorials 

The Publication Committee is not responsible for the authenticity of opinion or statements made by authors or 
in communications submitted to this Journal for publication. The author shall be held entirely responsible. 
Editorials printed in The Journal do not necessarily reflect the official position of the West Virginia State 
Medical Association. 


One can still hear around Medical Society 
meetings comments to the effect, “What the 
profession needs is some good public relations. 
The public just doesn't know enough about 
what goes on in Medicine to appreciate what 
they’ve got . . 

Perhaps this was once true. But in recent 
years we’ve been getting publicity, lots of it. It’s 
hard to pick up a newspaper these days without 
finding prominently displayed some story de- 
picting medical technological wizardry being 
applied to some unfortunate victim 
PUBLIC of d isease or accident. Medical 

RELATIONS columns by physician journalists 
are rampant. News services scan 
scientific journals and frequently announce 
scientific advances before the mailman delivers 
the journals. No news magazine worthy of the 
name is without its Medicine section. Television 
networks have full-time medical experts appear- 
ing in popular time spots discussing common 
or rare afflictions and giving advice. Publishing 
houses solicit manuscripts and print books on 
diets, exercise programs and a host of medical 
fads. 

One might be led to think now that, rather 
than being medically uneducated, the public 
knows too much. And knowing too much, they 
expect too much. “Why shouldn't my father 
(husband, son, mother, wife, cousin . . .) have 
an artificial heart like that dentist?” Or, more 
likely, “If they can put an artificial heart in that 
dentist and keep him alive, why did my father 
(husband, son, mother, wife, cousin . . .) die 
of a little thing like a ruptured ulcer 
( ruptured spleen, ruptured aorta, pulmonary 
embolus . . .)?” 

The increased medical sophistication of the 
public has not led to increased respect and 
appreciation for doctors. PDR’s are a big seller; 
patients now want to quiz the doctor on his 
knowledge of drug side effects and incompati- 
bilities, and, frequently enough, to negotiate on 
which might be the drug of choice to treat their 
condition. 


Good public relations were supposed to make 
life better for the doctor and patients easier to 
deal with. Sadly, that has not happened. 
Patients are now informed and doctors now 
struggle to get informed consent. Patients are 
smarter and less trusting. Patients and doctors 
alike now have personal attorneys. Where a 
family once had a bottle of Mercurochrome and 
a tin of aspirin in its medicine cabinet as its 
bow to medical preparedness, they now have a 
sphygmomanometer. 

There wasn't really too much that was good 
back in the good old days of Medicine but a 
medically unsophisticated patient was surely a 
pleasure. There are certainly others about in 
need of good public relations ... if we could 
only tout the reporters onto them somehow, 
maybe . . . 


It’s not a mnemonic. It is hardly even an 
attractive group of initials, suggesting at best, 
perhaps not inappropriately, a dirge. But if 
HCFA, a not very attractive group of letters 
either standing for Health Care Financing 
Administration of the Department of 
DRGs Health and Human Services, has its 
way, these will soon be as well known 
to physicians as IRS or FTC. 

Diagnosis Related Groups. Practically all of 
Medicine is wrapped up into 467 of them. An 
industrial engineer with a special knowledge of 
industrial quality control accomplished this 
remarkable task of distillation. A medical 
product has been described; the production 
process defined; and a cost control method 
created. 

The system developed is to be applied to 
hospitalized patients paid for by Medicare. 
Other third-party payors have shown a keen 
interest in employing the same or a similar pro- 
gram for their subscribers. Presently, it is to 
apply only to hospital charges, not to physician 
fees. 

Although the payment mechanism has been 
described as prospective, the actual payment is 


s : ' F 
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\u r 


5 


April. 1983, Vol. 79, No. 4 


85 


AH.VU.an S 33 K 5 Q 5 



based on a discharge diagnosis for each covered 
individual. The discharge diagnoses are what 
constitute the DRGs. They are complex and 
arborized along the lines of an algorithm: the 
first division is surgical-nonsurgical; the next, 
complications; then concomitant conditions; 
age; discharge status; etc., etc., etc. 

The final elaborated diagnostic form festooned 
with all pertinent problems and procedural infor- 
mation is matched with one of the 467 DRGs, 
each of which carries with it a set dollar figure 
tailored to the particular geographical area and 
type of hospital. 

One set price, no matter the LOS, time in 
ICU, number of C-Ts, EEGs, the size of the 
stack of x-rays or sheath of laboratory studies. 
Hospital administrators are worried. The staff 
could break them. Schemes to marry the clinical 
and administrative functions of hospital care are 
proliferating. 

It’s a time for innovation. It is a time for 
medical staff to be on their collective toes and 
to enter into the process of shaping whatever 
change is required. 

Some form of a hospital payment system 
using DRGs seems imminent. If physicians are 
to ignore the clear handwriting on the wall on 
this issue, DRGs could spell DOA to the 
amicable medical staff-hospital relations such as 
we presently enjoy. 



Unusual Case In State 

Rocky Mountain Spotted Fever (RMSF) is an uncom- 
mon disease in West Virginia, with only eight reported 
cases in 1982. 1 It is diagnosed more often in the border- 
ing states of Maryland and Virginia, with 50 and 73 cases, 
respectively, last year. 1 Peak incidence is in the spring 
and summer months when both ticks and humans are 
active in the outdoors. 2 So, we were surprised to find 
a January RMSF case in central West Virginia. 

A 14-year-old white male, a resident of West Milford 
in Harrison County, presented to the Emergency De- 
partment of United Hospital Center in Clarksburg on 
January 15, 1983. He complained of an eight-day illness 
which started with intermittent fever to 102°F, head- 
ache, and myalgia. He had been seen in the office on 
the third day of the illness, at which time he appeared 
mildly ill, and had a temperature of 102°F, but otherwise 
had a normal examination. He was sent home on sympto- 
matic treatment for a presumed viral illness. 

A throat culture was taken and was negative for Strep- 
tococcus. His symptoms worsened and his evening tem- 
perature spikes reached 104°F. On the sixth day of the 
illness, a macular, mildly pruritic rash appeared on his 
hands and feet and spread inwards. He also developed 
a mild sore throat and had increased myalgia in his legs. 

He denied any history of tick bite, although the family 
does have two dogs. He had hunted and helped his 
brother with trapping this winter, and had limited con- 


tact with killed rabbit and other animals. The family 
lives in an old house and has a problem with rats. He 
had no known contact with contaminated water or food- 
stuffs, had not traveled recently, and had never been 
outside the northeastern United States. No one else in 
the family was ill. The only medication was ace- 
taminophen (Tylenol); he has no known drug allergies. 

On admission, the temperature was 103. 8°F; pulse, 
88, and respiration, 20. He appeared moderately ill. 
Examination showed muscle tenderness on palpation of 
the lower extremities, and two rashes: one, a fine, 
petechial, hemorrhagic rash most prominent on his 
lower legs, ankles, and soles; the other, an erythematous, 
macular, papular rash on his extremities, face and trunk,- 
which disappeared during the course of the examination. 
The examination was otherwise unremarkable. , 

Admission hemogram showed a white count of 6,600 
with 33 stabs, 23 polys and 44 lymphs; hemoglobin, 
13.0 gm; MCV, 86.1, and platelet count, 119,000. Wes- 
tergren ESM was 6 mm/hr. Urinalysis was normal. 
Mono spot was negative. RPR was non-reactive. Febrile 
agglutinins drawn on admission were positive for Proteus 
OX2 at a titer of 1:80 and Proteus OX19 at a titer of 
1:40; Proteus OXK, Typhoid H. Typhoid O, Brucella, 
and Pasturella tularensis were negative. Cold agglutinins 
were positive at a titer of 1:8; acute Mycoplasma and 
Leptospira titers were negative. Blood cultures and re- 
peat throat culture showed no growth. ASTO titers were 
negative. Chemical profile showed alkaline phosphatase 
elevated at 245 IU/L, LDH elevated at greater than 
600 IU/L, and SGOT elevated at 168 IU/L. Chest 
x-ray and EKG were normal. 

The patient was treated with doxycvcline (Vibramvcin) 
200 mg. po stat, then 100 mg. po b.i.d. He also received 
acetaminophen for fever and hydroxazine I1CL (Atarax) 
for itching. At no time did he appear more than mod- 
erately ill. The petechial rash persisted but did not 
worsen. The platelet count dropped to 89,000 on the 
second hospital day, then rose. He had several more 
transient episodes of a macular, papular rash which at 
times had a sandpaper-like texture, and also had epi- 
sodes of transient, pruritic, urticarial rash. He continued 
to have evening temperature spikes which gradually de- 
creased, and became afebrile on the fourth day of treat- 
ment. He was discharged home on doxycycline 100 mg. 
po daily to finish a 10-day course. 

He was seen in the office one week later, at which 
time he felt entirely well. Convalescent titers were ob- 
tained two weeks after the acute titers had been drawn. 
Convalescent Proteus OX2 was positive at a titer of 1:320, 
showing a four-fold rise; Proteus 0X19 was 1:320, show- 
ing an eight-fold rise. Other febrile agglutinins again 
were negative, as was repeat mono spot and Mycoplasma 
titers. Leptospira titers, and a hepatitis screen. 

Comment 

This patient had a fairly typical presentation for 
RMSF, except that the illness was milder than expected 
from textbook descriptions, and that a tick-borne zoonosis 
is unexpected in January in West Virginia. The serology 
is typical for RMSF; murine (endemic) typhus also could 
give these results, but we feel the nature of the rash con- 
firms the diagnosis of RMSF. 

We assume the unusually warm winter has allowed 
continued risk of tick exposure. Also of note for central 
West Virginia physicians is the focal nature of RMSF 
cases, with limited geographic areas accounting for a 
high percentage of cases in a given state. 2 


1. MMWR 31:52, 705 01/07/83 

2. Scientific American Medicine 7: XI : 1 

Allen L. Knowles III, M.D., PG II 
Peter Id. Oostwouder, M.D., PG I 
Family Practice Residency 
United Hospital Center, Clarksburg 

L. Dale Simmons, M.D. 

Director, Family Practice Residency 
UHC, Clarksburg 


86 


The West Virginia Medical Journal 


GENERAL NEWS 


VD, Gay Patient Diseases 
Convention Subjects 

Venereal diseases and diseases of the gay 
patient will be discussed by physicians from 
Marshall University and the University of Pitts- 
burgh during the State Medical Association’s 
116th Annual Meeting. 



Lee P. Van Voris, M. D. George J. Pazin, M. D. 


The two papers will be part of a “Symposium 
on Sexually Transmitted Diseases ” constituting 
the initial general scientific session on Friday 
morning, August 26. 

The convention will be held August 25-27 at 
the Greenbrier in White Sulphur Springs. 

Dr. Lee P. Van Voris, MU Associate Pro- 
fessor of Medicine, will speak on “Non-Luetic. 
Non-Gonococcal Venereal Diseases,” and Dr. 
George J. Pazin, Associate Professor of Medi- 
cine at the University of Pittsburgh, will dis- 
cuss “Transmissible Diseases of the Gay 
Patient,” the Program Committee announced. 

Other individual topics for the Friday morning 
session will be syphillis and gonococcal infec- 
tions, and sexual mores in the 1980s. The ses- 
sion will follow traditional opening exercises; 
the keynote speaker for the latter program will 
be announced later. 

The Annual Meeting will open with a pre- 
convention session of the Association’s Council 
and the first session of the House of Delegates 
on Thursday morning and afternoon; and end 
with the second and final House session and 


reception for new Association officers on 
Saturday afternoon and evening. 

Doctor Van Voris, effective in May, will leave 
MU to become Chief of Infectious Diseases and 
Hospital Epidemiologist at Hamot Hospital in 
Erie, Pennsylvania. He will have the con- 
tinuing appointment, however, as MU Clinical 
Associate Professor of Medicine. He has been 
on the MU faculty since 1978. 

Doctor Van Voris was graduated from 
Kenyon College in Gambier, Ohio; received his 
M. D. degree in 1971 from State University of 
New York ( SUNY ) Upstate Medical Center. 
Syracuse; interned at Los Angeles County 
Harbor General Hospital in Torrance, California; 
and completed residencies at that hospital and 
at SUNY Medical Center, Syracuse. He received 
a fellowship in infectious diseases from 1976 
to 1978 at the University of Rochester (New 
^ ork ) . 

Certified in internal medicine, Doctor Van 
Voris is a Fellow of the American College of 
Physicians, and a member of the Board of 
Directors, West Virginia Chapter, Association 
for Practitioners in Infection Control. 

He is the author or co-author of four books 
and/or book chapters, 10 abstracts, and 18 
scientific articles. 

‘Pitt’ Graduate 

Doctor Pazin is a graduate of the University 
of Pittsburgh School of Medicine and the Uni- 
versity’s Health Center Hospitals program in 
internal medicine. During an academic fellow- 
ship in infectious diseases under Dr. A. 1. 
Braude, he also earned a M. S. degree in micro- 
biology. 

Doctor Pazin served two years in the Venereal 
Disease Branch of the U. S. Public Health 
Service at the Centers for Disease Control in 
Atlanta, Georgia, and completed his infectious 
disease fellowship at the University of California, 
San Diego, before returning to the University 
of Pittsburgh. Board certified in internal medi- 
cine and infectious diseases, he has published 
in a wide range of areas from interferon and 
herpes viruses to aminoglycoside pharma- 
cokinetics in obesity; office bacteriology; candi- 
diasis; endocarditis; gonorrhea, and “Pittsburgh 
pneumonia agent.” 


April, 1983, Vol. 79, No. 4 


87 


His main research efforts during the past five 
years have involved investigations of the clinical 
applications of human leukocyte interferon in 
relation to: (1) reactivation of herpes simplex 

virus following neurosurgery, (2) treatment of 
extensive skin papillomas (warts) in a patient 
with atopic eczema, and ( 3 ) treatment of genital 
herpes in women. 

The second general scientific session will be 
held Saturday morning, August 27’ and, as 
announced previously, will be a symposium on 
cardiovascular diseases. The Saturday morning 
topics will include new developments in the 
management of cardiac arrhythmias; an update 
relative to cardiovascular surgery, and the 
management of congestive heart failure. 

Special Groups 

In addition to the general sessions, the Annual 
Meeting agenda will include breakfast, luncheon 
and other programs arranged by specialty 
societies and sections, many of which also will 
provide scientific discussions. 

The specialty group meetings will be held in 
large measure on Friday, with a few to be set 
for Saturday morning, preceding the second 
general sesion, and at noon. 

At the final House session on Saturday after- 
noon, Carl R. Adkins, M. D., of Oak Hill will he 
installed as the Association’s 1983-84 President 
to succeed Harry Shannon, M. D., of Parkers- 
burg. 

The Auxiliary to the State Medical Associa- 
tion, with Mrs. Richard S. Kerr of Morgantown 



Putting their heads together during the recent 
16th Mid-Winter Clinical Conference in Charleston 
are, from left, Drs. Harry Shannon of Parkersburg, 
President of the State Medical Association: Jack 
Leckie, Huntington; and David Z. Morgan, Morgan- 
town. The annual continuing education program is 
sponsored by the Association and the West Virginia 
University and Marshall University Schools of 
Medicine. 


the current President, as usual will hold its 
meeting in conjunction with that of the Associa- 
tion. 

Members of the 1983 Program Committee 
are David Z. Morgan, M. D., Morgantown, 
Chairman; Doctor Adkins; Jean P. Cavender, 
M. D., Charleston: Michael J. Lewis, M. D., St. 
Marys; Kenneth Scher, M. D., Huntington, and 
Roland J. Weisser, Jr., M. D., Morgantown. 

Additional information concerning speakers 
and other convention details will be provided 
in upcoming issues of The Journal. 


Legislature Enacts Hospital, 
Nurse, Therapist Measures 

Bills establishing a hospital cost containment 
authority, and easing registered nurses — regard- 
less of levels of training — and physicial ther- 
apists into independent practice sailed through 
the recent legislative session during its final 
hours. 

Failing to pass were bills to extend from 1984 
to 1987 temporary permit mechanisms for un- 
licensed physicians, and require parental notifi- 
cation prior to the performing of an abortion on 
a minor. 

The controversial nurses legislation will re- 
quire, as of January 1, 1984, third-party re- 
imbursement for non-salaried primary health 
care nursing services and can cause substantial 
problems for the insurance industry and others. 

The West Virginia Nurses Association has 
emphasized in its publication that its goal has 
been recognition of the independent practice of 
nursing, and to provide “the citizens of West 
Virginia with the freedom to choose between 
various health care providers.” 

Referrals No Longer Required 

The physical therapist bill will permit those 
licensed individuals to treat persons other than 
those referred by physicians, dentists or podia- 
trists, as the law has required. 

The bill, heavily lobbied by freshman Dele- 
gate Joe Manchin III (D-Marion), was passed 
finally by the Senate, 26-4, just two minutes 
before the end of the regular session at midnight 
on Saturday, March 12. 

The final Senate vote, held up for several days, 
followed Manchin’s eventual support of a largely 
Senate version of the hospital cost containment 
bill, passed in the Senate 21-13 and in the House 
63-34 after adoption of a conference committee 
report. 

As this copy was written on The Journal dead- 
line for the April issue, more detail on the hos- 


88 


The West Virginia Medical Journal 


pital and other legislation will be developed 
later. The Legislature provided for a three- 
member rate-review and rate-setting authority to 
be established within the West Virginia Depart- 
ment of Health structure (see story on page 91). 

Other bills enacted by the Legislature, if 
approved by the Governor, will: 

- — Set up a procedure for patients, upon 
written request, to obtain from health care pro- 
viders copies or summaries of their medical 
records — with safeguard covering doctors’ notes, 
psychiatric situations and others (legislation 
prepared and strongly supported by the State 
Medical Association). 

— Require that at least 40 per cent of hospital 
boards of directors be representatives of small 
business, organized labor, the elderly and per- 
sons with income less than the national median. 

— Permit certain authorized personnel to pro- 
vide corneas to the state medical eye bank 
pursuant to an autopsy (supported by the State 
Medical Association). 

— Eliminate chest x-rays for school personnel 
and children unless medically indicated. 

— Provide for licensure by the West Virginia 
Department of Health of birthing centers; and 
authorize use of certain state funds for payment 
of birthing center services. 

— List specific birth defects to be reported to 
the West Virginia Department of Health in 
further implementation of a 1982 act supported 
by the State Medical Association. 

— Revise and tighten educational and other 
requirements for Type B physician assistants. 

— Provide that investigators appointed by the 
West Virginia Board of Pharmacy need not be 
registered pharmacists. 

— Update the list of controlled substances in 
line with West Virginia Board of Pharmacy 
recommendations. 

— Re-establish a 10-member Workers’ Compen- 
sation Fund Advisory Board, with three mem- 
bers representing providers of medical services 
to employees for which such providers are 
compensated by the fund (supported by the 
Sate Medical Association ) . 

— Permit the State Health Director to make 
emergency payments for certain health care 
services. 

— Rename the Department of Welfare the 
Department of Human Services. 

— Rename the Workmen's Compensation 
Fund the Workers’ Compensation Fund. 


Continuing Education 
Activities 


Here are the continuing medical education 
activities listed primarily by the West Virginia 
University School of Medicine for part of 
1983, as compiled by Dr. Robert L. Smith, 
Assistant Dean for Continuing Education, and 
J. Zeb Wright, Ph. D., Coordinator, Con- 
tinuing Education, Department of Community 
Medicine, Charleston Division. The schedule is 
presented as a convenience for physicians in plan- 
ning their continuing education program. (Other 
national, state and district medical meetings are 
listed in the Medical Meetings Department of 
The Journal.) 

The program is tentative and subject to 
change. It should be noted that weekly confer- 
ences also are held on the Morgantown, Charles- 
ton and Wheeling campuses. Further information 
about these may be obtained from: Division of 
Continuing Education, WVU Medical Center, 
3110 MacCorkle Avenue, S. E., Charleston 
25304: Office of Continuing Medical Education, 
WVU Medical Center, Morgantown 26506; or 
Office of Continuing Medical Education, Wheel- 
ing Division, WVU School of Medicine, Ohio 
\ alley Medical Center. 2000 Eoff Street, Wheel- 
ing 26003. 

April 12, Summersville, Child Abuse & Neglect, 
Part I (Sponsor. WVU Charleston Division) 

April 15, Charleston, Aspiration Biopsy Cytology 
April 15-16. Morgantown. Cancer Teaching Days 

April 19, Summersville, Child Abuse & Neglect 
Part II I Sponsor, WVU Charleston Division ) 

April 21-22. Morgantown, Workshop for Infec- 
tion Control Practitioners 

April 28, Wheeling, Balance Disorders 
April 29, Charleston, Research Day 
April 29-30, Morgantown, Orthopedic Reunion 
Days 

May 7, Charleston, Outpatient Infectious Dis- 
eases 

May 20-21, Morgantown, Health Officers Con- 
ference 

June 3-4, Morgantown. Anesthesia Update ’83 
June 4, Charleston, 10th Annual Wildwater 
Conference — Medical & Surgical Update 

June 11, Morgantown, Interventional Radiology 
(continued on next page) 


April, 1983, Vol. 79, No. 4 


89 



Regularly Scheduled Continuing 
Education Outreach Programs from 
WVU Medical Center/ 
Charleston Division 

Buckhannon, St. Joseph's Hospital, first-floor 
cafeteria, 3rd Thursday, 7-9 P. M. — April 
21, “Prenatal Disorders and Congenital 
Anomalies, R. Stephen S. Amato. M. D. 
May 19, “Evaluation of Infertility and Fre- 
quent Spontaneous Abortions,” Bruce L. 
Berry, M. D. 

June 16, “Sudden Infant Death Syndrome,” 
David Myerberg, M. D. 

Cabin Creek, Cabin Creek Medical Center, 
Dawes, 2nd Wednesday. 8-10 A. M. — April 
13, “Overall Outpatient Management of Renal 
Dysfunctions, Mary Lou Lewis, M. D. 

May 11, “Hypertension Update,” Steven 
Grubb, M. D. 

Cassaway, Braxton Co. Memorial Hospital, 1st 
Wednesday, 7-9 P. M. — April 6, “Clinical 
Intervention in Drug & Alcohol Abuse,” 
Thomas Haymond, M. D. 

Madison, 2nd floor. Lick Creek Social Services 
Bldg., 2nd Tuesday, 7-9 P. M. — April 12. 
“Allergy Update,” Joseph Skaggs, M. D. 

May 10, “Common Dermatological Problems,” 
Stephen K. Milroy, M. D. 

June 14, “Recently Recognized Sexually - 
Transmitted Diseases,” Thomas W. Mou. 
M. D. 

July 12, “Approach to the Peripheral Vascular 
Patient,” Ali F. AbuRahma, M. D. 

Oak Hill, Oak Hill High School ( Oyler Exit, N 
19) 4th Tuesday, 7-9 P. M. — April 26, 
“Adolescent Sexuality: Recognizing & Treat- 
ing Pathological Behavior,” T. 0. Dickey, 
M. D., and Art Kelley, M. D. 

IV elch, Stevens Clinic Hospital, 3rd Wednesday, 
12 Noon-2 P. M. - — April 20, “Emotional 
Trauma of Cancer,” Sr. Frances Kirtley, R.N., 
and Sue Warren, M. D. 

Wlutesville, Raleigh-Boone Medical Center, 4th 
Wednesday, 11 A. M.-l P. M. — April 27, 
“Obesity: Emotional Factors in Compliance,” 
John Linton, Ph.D. 

IV illiamson, Appalachian Power Auditorium, 1st 
Thursday, 6:30-8:30 P. M. — April 7, “Lower 
Back Injury,' Robert Ghiz, M. D. (a special 
program in cooperation with Workers’ Com- 
pensation Fund of West Virginia) 


Senate Confirms Physicians 
For State Agency Roles 

Executive appointments confirmed by the 
State Senate during the recent legislative session 
included the following: 

Vest Virginia Board of Medicine: S. Eileen 
Catterson. M. D., Rhodell in Raleigh County 
Ifor a term to end September 30, 1985); 
Thomas Harward, Belington physician’s assistant 
( September 30, 1987 ) ; Frank J. Holroyd, M. D.. 
Princeton (September 30, 1987); Dr. Leonard 
Simmons, Fairmont podiatrist (September 30. 
1987): Joseph T. Skaggs, M. D., Charleston 
(September 30. 1983 ), and Mrs. Frances Groves, 
Martinsburg, lay member (September 30, 1987). 

West Virginia Racing Commission: Robert 

S. Straueh, M. D., Martinsburg (March 21. 
1986). 

Nursing Home Administrator’s Licensing 
Board: Earl Fisher, M. D., Gassaway (June 30. 
1986). 


Review A Book 


The following books have been received by the 
Headquarters Office of the State Medical Associa- 
tion. Medical readers interested in reviewing any 
of these volumes should address their requests to 
Editor. The IVest Virginia Medical Journal. Post 
Office Box 1031. Charleston 25324. We shall be 
happy to send the books to you. and you may 
keep them for your personal libraries after sub- 
mitting to The Journal a review for publication. 

Basic and Clinical Pharmacology , by Bertram 
G. Katzung, M. D., Ph.D. 815 pages. Price 
$23.50. Lange Medical Publications, I,os Altos, 
California 94022. 1982. 

Nine Months' Reading : A Medical Guide for 
Pregnant JV omen, 3rd Edition, by Robert E. 
Hall. M. D. 178 pages. Price $13.95. Double- 
day & Company, Inc., 245 Park Avenue, New 
Y ork. New York 10167. 1983. 

Living With Herpes, by Deborah P. Langston. 
M. D. 198 pages. Price $7.95. Doubleday & 
Company, Inc., 245 Park Avenue, New York. 
New York 10167. 1983. 

Current Medical Diagnosis and Treatment, 
1933. edited by Marcus A. Krupp, M. D.; and 
Milton J. Chatton, M. D. 1130 pages. Price $24. 
Lange Medical Publications, Los Altos, Cali- 
fornia 94022. 1983. 


90 


The West Virginia Medical Journal 



Act Freezes Hospital Rates, 

Sets Up Review Board 

A 1983 legislative act entitled the West Vir- 
ginia Health Care Cost Review Authority has 
frozen all rates for hospital services in effect as 
of February 1, 1983. and has put a cap on hos- 
pitals gross patient revenues that permits no 
more than a 12-per cent annual increase. 

This same voluminous enactment, effective 
from its March 12 passage date, sets up as an 
autonomous entity in the West Virginia Depart- 
ment of Health a three-member West Virginia 
Health Care Cost Review Authority to review 
and set hospital rates. 

For physicians, key language in a section 
setting forth the jurisdiction of the review board 
will be of prime interest. Promulgation of ad- 
ministrative rules and regulations to carry out 
provisions of the act will be necessary to clarify 
the eventual effect of the legislation. 

The board, or review authority, will — as of 
July 1, 1984 — begin taking jurisdiction as to 
rates for health services care as they extend to 
all acute care hospitals in the state except those 
owned and operated by the federal government. 

Other Rates Covered 

The act says that board jurisdiction also will 
extend to other rates as follow's: 

“Those costs or charges associated with indi- 
vidual health care providers or health care pro- 
vider groups providing inpatient or outpatient 
services under a contractual agreement with 
hospitals (excluding simple admitting privi- 
leges) . . . 

“The jurisdiction of the board shall not 
(emphasis ours) extend to the regulation of 
rates of private health care providers or health 
care groups providing inpatient or outpatient 
services under a contractual agreement with hos- 
pitals when the provision of such service is out- 
side the hospital setting.’" 

The act further stipulates that the board shall 
not regulate rates of other private health care 
providers practicing outside the hospital setting: 
“provided, that such practice outside the hospital 
setting is not found to be an evasion of the pur- 
pose of this article (that setting up the new 
review authority).” 

Compromise Passed in House 

The Senate-House compromise that produced 
the new legislation was passed finally in the 
House at 11:48 P. M. on Saturday. March 12 — 
just 12 minutes before the end of the regular 


60-day session I except for an extension of three 
days to consider only the state’s operating 
budget for 1983-84). 

The voting climaxed feverish activity which 
reached the panic-button stage in the final few 
hours, and left in confusion those trying to keep 
track of what Senate and House conferees were 
putting together. 

Not until Monday, March 14, was it possible 
to get a reasonably clear picture of all of the 
provisions of the act, which essentially took the 
form of the Senate bill passed earlier in the 
session. There was time for only very sketchy 
floor explanations of the conference agreement 
before the bill was passed first in in the Senate, 
then the House. 

Lost in the late shuffle of papers and negotia- 
tions, apparently, was a spot for a physician as 
one of seven voting members on a 12-member 
advisory council to assist the three-member re- 
view authority. 

Voting Members 

Information available during Saturday even- 
ing indicated that the physician spot was assured 
— but as the final version unfolded, the voting 
members will include a health insurance industry 
representative; an administrator of a large hos- 
pital; a small-hospital administrator, and four 
consumers. 

The voting members, who will serve along 
with five heads of state departments, will — like 
the three board members — be appointed by the 
governor for specific terms, subject to Senate 
confirmation. 

The new authority also will become the state’s 
health planning and development agency as of 
July 1, 1984, and take over functions and 
responsibilities of the certificate of need pro- 
gram for capital expenditures for health care 
facilities and specified services. 

As indicated in another article in this news 
section, further elaboration on this and other 
legislation will come in subsequent issues of The 
Journal. 


Residents Total Slows 

The number of resident physicians in the 
United States dropped percentagewise from 1976 
to 1981. according to recently released figures 
from the American Medical Association Physi- 
cian Masterfile. In 1976, 15.4 per cent of all 
physicians were residents. They made up 13.0 
per cent of the physician population in 1981 — 
a drop of 2.4 per cent. 


April, 1983, Vol. 79, No. 4 


91 


Management Process Seminar 
Scheduled In Bethany 

An April 15-17 weekend of training on “The 
Management Process for 1983 is being co- 
sponsored by the Governor’s Small and Minority 
Business Services of the Governor's Office 
of Economic and Community Development. 
Bethany College and the United States Small 
Business Administration. The seminar will be 
held at the Bethany Leadership Center at 
Bethany, West Virginia. 

Also participating are the West Virginia 
Small Business Development Centers of Charles- 
ton and Clarksburg, and the West Virginia U ni- 
versity Business and Management Extension 
Office. 

This program is open to the public, those in 
business or those who are interested in starting 
a business. 


Book Features State Native 

Neurosurgeon Thomas B. Ducker, M. D., a 
native of Huntington, is featured in a new book. 
Not Quite a Miracle I Doubleday), The Journal 
has learned. Doctor Ducker is Chief Neuro- 
surgeon at the University of Maryland Hospital 
in Baltimore. 

The book was inspired by a Pulitzer Prize- 
winning story about Doctor Ducker. In that 
story, the neurosurgeon attempted to remove a 
deadly blood vessel malformation from the brain 
of a Baltimore woman. In the new book, Doctor 
Ducker, a 1955 Huntington High School gradu- 
ate, is depicted in true stories involving a num- 
ber of patients. 



Enjoying a coffee break during the Mid-Winter 
Clinical Conference held recently in Charleston are, 
from left, Drs. James E. Boggs, Ivydale (Clay 
County), and J. L. Mangus and Ralph H. Nestmann, 
both of Charleston. Some 250 physicians and others 
attended the annual continuing medical education 
event. 


Doctor Mufson Presents 
Paper In Norway 

Dr. Maurice A. Mufson of the Marshall Llni- 
versity School of Medicine and the Huntington 
Veterans Administration Medical Center partici- 
pated in an international scientific symposium 
in March in Beitostolen. Norway. Doctor Muf- 
son. Chairman of the school’s Department of 
Medicine, presented a paper on “Mycoplasma 
hominis — A Review of its Role as a Respiratory 
Tract Pathogen of Man.“ 

He said the meeting provided the most up-to- 
date review of M. hominis, which can cause 
pneumonia and tonsillitis and may be linked to 
serious lung disease in newborns. 

The symposium was underwritten by the U. S. 
Food and Drug Administration, the World 
Health Organization, the International Organiza- 
tion of Mycoplasmology and the Scandinavian 
Society for Genitourinary Medicine. 

Doctor Mufson is a member of the Program 
Committee for the annual January Mid-Winter 
Clinical Conference sponsored by the State Medi- 
cal Association and the MU and West Virginia 
University Schools of Medicine. 


Anesthesiologists Plan 
Meeting June 3-4 

Speakers from Texas, Pennsylvania, Virginia 
and Maryland will make up the guest faculty 
for the annual meeting of the West Virginia 
State Society of Anesthesiologists June 3-4. 

The meeting, “Anesthesia Llpdate ’83,” will be 
held in Morgantown at the Holiday Inn. 

Guest faculty members will be Yadin David. 
Ed.D., Texas Heart Institute, Houston, who will 
speak on “Anesthetic Vaporizers — Performance 
Assurance Program;” and Drs. Norig E. Ellison, 
University of Pennsylvania, “New Trends in 
Intraoperative Blood Transfusions; David E. 
Longnecker, University of Virginia, “Anesthetic 
Considerations in Hypertension;" and Robert W. 
McPherson, Johns Hopkins University, “The 
Effects of Anesthetic Agents on Intraoperative 
Neurological Monitoring.” 

Speakers from the Department of Anesthesi- 
ology at West Virginia University Medical 
Center will be Drs. Robert Bettinger, “Use of 
Epidural Narcotics;” Gary S. Sklar. “Control of 
Ad verse Psychological Reactions to Ketamine;” 
and Barry L. Zimmerman, "Invasive Monitor- 
ing: What Do the Numbers Mean?.” 


92 


Tin: West Virginia Medical Journal 


Collection Service Outlines 
Background, Operation 

Editor s Note: The 1. C. System, Inc., of St. 
Paul, Minnesota, as reported previously, has 
been recommended by the State Medical As- 
sociation as a collection agency for West Vir- 
ginia physicians. The company has submitted 
the following release providing additional infor- 
mation about its background and operations. 

“Members [of the West Virginia State Medical 
Association] now have a uniform collection 
system approved for their use. It employs the 
latest techniques available, consistent with all 
requirements and provisions of the increasingly 
strict laws governing collection practices. The 
official announcement letter to members outlined 
the program, but did not go into the particular 
qualifications of the company chosen to serve the 
membership, I. C. System, Inc. 

“I. C. System has been in the collection busi- 
ness since 1938. It now serves the members of 
over 1,000 state business and professional as- 
sociations and societies all across the country. 
The company is currently collecting at a rate of 
some $5 million per month in past-due accounts. 

“All collection practices, procedures and ma- 
terials used by I. C. System have been scruti- 
nized by the Federal Trade Commission. So 
without reservation, all members can be assured 
that the company is fully aware of what can and 
cannot be done on behalf of its clients. And 
I. C. System's hold-harmless indemnity agree- 
ment assures members that they are in no danger 
of legal action resulting from collection activities 
carried out by the company on their behalf. 
That’s particularly important in this age of con- 
sumerism. 

Entrusting Name 

“Years ago, the most important consideration 
in selecting a collection service was to determine 
its ability to collect and its willingness to turn 
over to the creditor all the money he had coming 
to him. Today, such selection equally empha- 
sizes the importance of entrusting one’s own 
good name and reputation to the collection 
service ... a heavy responsibility. 

“Keeping pace with the increases in collec- 
tions over the years has been development of 
improved data processing and customer service 
departments. The company has a modern, tailor- 
made data processing system backed up by auto- 
matic typewriters, microfilm equipment and a 
complete in-house printing and mailing cap- 
ability. This enables the company to keep pace 

April. 1983, Vol. 79, No. 4 


with its growth and to respond immediately to 
customer needs and inquiries. 

“The company maintains a staff of customer 
relations personnel whose job it is to see that 
all customer inquiries are handled on a “right 
now” basis. And for those situations in which 
the mail cannot carry information fast enough, 
the creditor can telephone the company via their 
toll-free WATS line system. 

“Borrowing from the experience of users in 
other states, members who install the system 
should submit nine or more accounts immedi- 
ately. Even if it’s necessary to go back a year 
or more to come up with that many bad checks 
or written-off accounts, it’s well worth the effort. 
You can expect as high a percentage of collec- 
tions on the very old accounts, but the initial 
heavy use will get your people accustomed to 
working with the service and thus less likely to 
overlook future accounts as they become 60 or 
90 days past due. A company representative 
will be happy to spend some time with your 
people to start things off on the right foot. 

“Those members who did not return the 
inquiry card enclosed with the original an- 
nouncement letter can arrange to see a repre- 
sentative at a later date by simply contacting 
the office.” 


State Psychiatrist To Talk 
In Ohio, Maryland 

Dr. Edmund C. Settle. Jr., of Charleston will 
be the featured speaker in a one-day educational 
program sponsored by the Wright State Uni- 
versity School of Medicine on April 16 in 
Columbus. Ohio. The program has been planned 
for a statewide audience of primary' care physi- 
cians, and will deal with the care of psychiatric 
patients in primary practice. 

The meeting is under the combined auspices 
of the Ohio Department of Health, the Depart- 
ments of Psychiatry and Family Practice of 
Wright State University School of Medicine, and 
the School of Nursing of Wright State. 

Doctor Settle, who is in private practice and 
is Clinical Associate Professor of Psychiatry at 
West Virginia University, also will be serving 
as moderator of a two-day symposium, “Affec- 
tive Disorders Reassessed: 1983,” at Taylor 

Manor Hospital in Ellicott City, Maryland, on 
April 8 and 9. This program will feature 
speakers with expertise in biologic aspects of 
psychiatry from the United States and Canada. 

93 


Child Abuse CME Program 
Set In Summersville 

A continuing medical education program on 
“Child Abuse and Neglect” will be presented 
in two sessions by the WVU Medical Center/ 
Charleston Division on April 12 and 19 in the 
Nicholas County Courthouse, Summersville. 
The time for both sessions will be from 7 to 9 
P. M. The featured speaker will be Kathleen 
Preville, M. D., Coordinator of Pediatric Clinics 
at the Charleston Area Medical Center. 

The first) session will focus on the medical 
aspects of child abuse and, the second, on con- 
sideration of the establishment of a county 
treatment plan. Co-sponsor for the program is a 
consortium of local civic groups and govern- 
mental agencies. All health professionals are 
welcome. 

The program is approved for four credit hours 
in Category 1 of the Physician’s Recognition 
Award of the American Medical Association, and 
.4 Continuing Education Units. 

For more information, contact Beth Jordan, 
R. N., at 872-4649 in Summersville, or John 
Aukerman at 347-1294, Division of Continuing 
Education, WVU Medical Center /Charleston 
Division. 


MU Succinimides Study 
Grant Received 

A Marshall University School of Medicine 
researcher has received a $201,997 grant to 
study why chemical compounds used as anti- 
epileptic drugs and fungicides ( and also found 
in cigarette smoke) sometimes cause kidney 
damage. 

Dr. Gary 0. Rankin, Associate Professor of 
Pharmacology, will study succinimides, a group 
of compounds with similar structures. He said 
scientists have known since the 1950s that some 
succinimides cause kidney damage. However, 
he believes very few researchers are trying to 
find out why they are toxic — and why others, 
such as the principal anti-epileptic drugs, are 
not. 

Doctor Rankin said kidney damage from suc- 
cinimides isn't a big problem in the LTnited 
States, but he believes it could become one. He 
noted that 1,000 succinimide-based drugs for 
epilepsy were introduced for testing between 
1966 and 1976. 

His three-year grant is funded by the National 
Institutes of Health. 


Medical Meetings 


April 7-8 — WV Chapter, Am. Academy of Pediatrics, 
Beckley. 

April 11-14 — Am. College of Physicians, San 
Francisco. 

April 15-17 — WV Chapter, AAFP, Morgantown. 

April 16-21 — Am. Academy of Pediatrics, Phila- 
delphia. 

April 17-21 — Am. Urological Assoc., Las Vegas. 

April 17-22 — Operative Treatment of Fractures & 
Nonunions (Johns Hopkins University), Hot 
Springs, VA. 

April 18-22 — Am. Roentgen Ray Society, Atlanta. 

April 21-23 — Medical & Chirurgical Faculty of MD, 
Cockeysville. 

April 22-24 — Medical Staff Leadership Seminar 
(Southern Medical Assoc.), Hilton Head, SC. 

April 23 — WV Diabetes Assoc., Charleston. 

April 24-28 — Am. Assoc, of Neurological Surgeons, 
Washington, D. C. 

May 2-6 — Am. Psychiatric Assoc., New York City. 

May 4-7 — WV Chapter, Am. College of Surgeons, 
White Sulphur Springs. 

May 6-8 — Southern Medical Assoc. Regional Post- 
graduate Conference, Lexington, KY. 

May 8-12 — Am. College of Obstetricians & Gyne- 
cologists, Atlanta. 

May 13-14 — Topics in Cardiovascular Diseases (Am. 
Heart Assoc.), Baltimore. 

May 19-20 — National Conference, Breast Cancer 
(Am. Cancer Society), Boston. 

May 20-22 — Am. Counseling Assoc., Morgantown. 

May 26-28 — Am. Assoc, of Genitourinary Surgeons, 
White Sulphur Springs. 

June 19-23 — Annual Meeting of AMA House, Chi- 
cago. 

Aug. 25-27— 116th Annual Meeting, W. Va. State 
Medical Assn., White Sulphur Springs. 

Sept. 29-Oct. 2 — Am. Society of Internal Medicine, 
San Francisco. 

Oct. 16-21 — Am. College of Surgeons, Atlanta. 

Nov. 6-9 — Scientific Assembly, Southern Medical 
Assoc., Baltimore. 


94 


The West Virginia Medical Journal 



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WVU Medical Center 
-News— 



Compiled from material furnished by the Medical Center 
News Service, Morgantown, W. Va. 


Unemployed Told Not To Go 
Without Treatment 

Physicians in WVU’s Medical Group Practice 
have told their patients that financial difficulties 
should not stop them from seeking needed medi- 
cal services. 

In a letter sent to each patient, the doctors 
note that special financial arrangements can be 
made to cover bills for necessary treatment. 

“Patients who bring to our attention their 
financial difficulties resulting from unemploy- 
ment can make some type of mutually agreed 
on payment schedule tailored to the patient’s 
current situation,” said Robert D’Alessandri, 
M. D., Chief of the Section on Comprehensive 
Medicine. 

“We do not want our patients to hesitate to 
seek needed medical care because of financial 
problems beyond their control. We have sent 
letters to all patients of the Medical Group 
Practice explaining this policy.” 

Up to 1,100 Seen Monthly 

Between 1,000 and 1,100 patients are seen 
each month in the Medical Group Practice, 
which is the outpatient general practice unit of 
the WVU Medical Center. 

Conrad Pesyna, Business Manager for the 
Medical Group Practice, says that since Novem- 
ber his office has been monitoring the number 
of patients having particular difficulty in making 
payments, and the number has increased signifi- 
cantly. 

“All of our patients are screened at each visit 
to determine their payment status. Those with 
financial problems are routed to the business 
office to make payment arrangements before 
seeing their doctor. 

“This has been our policy all along but since 
so many more patients are finding themselves 
in a financial bind and some are losing their 
health insurance coverage, we’re making a 

\iv 


special effort to assure our patients that special 
arrangements can be made if necessary,” Pesyna 
explained. 


Seven Students Elected To AO A, 
National Honor Society 

Seven third-year students in the WVU School 
of Medicine have been elected to the national 
honor medical society, Alpha Omega Alpha. 

Michael Nunley and Richard Weidman, both 
of Charleston; Richard Loeser, Huntington; 
Patrick Allender, Valerie Lazzell and Frederick 
Zeller, all of Morgantown, and Salvatore Paras- 
candola. West Babylon, New York, are WVU’s 
newest AOA members. 

They bring the total student membership to 
20, joining six from the fourth-year class who 
were elected last fall, and seven elected in their 
third year last spring. 

The others are Stephen Powell, Scott Depot, 
President; Anne C. Cutlip, Morgantown, Vice 
President; Carolyn Looney, Van Sant, Virginia, 
Charleston Division Vice President; Michael T. 
Angotti, Clarksburg; Linda Gray, Elm Grove; 
Lynn H. Harris, Baltimore; Richard J. Jackson, 
Martinsburg; Gary Renaldo and Ralph A. 
Sellers, Fairmont; Gregory D. Snodgrass, Gauley 
Bridge; Jack Steel, Barrackville; Vincent 
Traynelis, Morgantown, and Daniel W. Wilson, 
St. Marys. 

The WVU chapter also elected a faculty mem- 
ber, Dr. John A. Belis, Associate Professor of 
Urology, and an alumnus, Dr. Dominic Gaziano 
of Charleston. 


Better Eye Care For Workers 

A pilot program to encourage effective eye 
care for industrial workers has been launched 
by the American Academy of Ophthalmology 
under the direction of a WVU eye specialist, 
Dr. George W. Weinstein, Chairman of Ophthal- 
mology. The project is under way for an esti- 
mated 35,000 employes of U. S. Steel Corp. and 
Duquesne Light Co. in the Pittsburgh area. 

Tiik Wf.st Virginia Medical Journal 


A NATIONAL INDUSTRIAL BACK SYMPOSIUM 



June 22-26, 1983 

The GREENBRIER HOTEL 
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Gordon Clemons 
Larry Clevenger 
George Cottrill. MD 
Henry Goldberg. MD 
Judith Greenwood. PhD 
John Haight. JD 
Scott Haldeman. DC. MD 
Hamilton Hall. MD 


includes: 

Nelson Hendler. MD 
Jelfery Kreider 
Tom Lahman. MD 
John McClaughtery. JD 
Robin McKenzie. M.N.Z.M.T.A. 
T. Rothrock Miller. MD 
Hugh Murray. RPT 
Sally Oxley. RPT 
Malcolm Pope. PhD 
Patricia Posey. RN 
Stanley Presier. JD 


Carl Roncaglione. MD 
Norman Rosen. MD 
Charles Sadler. MD 
Herschiel Sims 
Terrence Strobbe.PhO 
Lloyd Sutter. JD 
Lawrence Thebo 
Samuel Weizel.MD 
E.W. Whitetord. MD 
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Includes a morning on Disability Evaluation of the Low Back 

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Third-Party News, Views 
and Program Concerns 



AMA Fears Loss Of Quality 
If DRGs Approved 

The American Medical Association has testi- 
fied against the Reagan Administration’s pro- 
posal to base Medicare payments to hospitals on 
the patient’s diagnosis. 

Appearing recently before the House Ways 
and Means Subcommittee on Health, Jerald 
Schenken, M. D., a pathologist from Omaha, 
Nebraska, and Vice Chairman of the AMA’s 
Council on Legislation, recommended that the 
committee “reject the Administration's proposal 
to impose an untried system across the nation.” 

He called instead for more prospective pay- 
ment demonstration projects and further analysis 
of the demonstration projects already in place. 

The AMA opposes “a radical change in the 
Medicare hospital reimbursement system without 
assurances that quality of care will be main- 
tained,” he explained. 

467 DRGs Proposed 

Doctor Schenken said the proposal, which 
would set a price for each of 467 diagnosis- 
related groups (DRGs) and which the Adminis- 
tration wants to implement nationwide October 
1 "has never been tried, even on a limited 
scale.” 

The DRG experiment in New Jersey, which 
began three years ago, differs significantly from 
the Administration proposal, and in any event, 
the New Jersey experiment has not been 
evaluated yet, he said. 

The Administration’s proposal, which was 
moving toward congressional approval as part of 
the Social Security package, aims to control the 
spiraling costs of Medicare, which now devotes 
68 per cent of its $60-billion budget to hospitals. 

Proponents of the plan say that if hospitals 
were paid per DRG, they would have an in- 
centive to be efficient. Hospitals now are 
reimbursed by Medicare on the basis of their 
costs. 

The DRG system divides illness into 467 
categories by primary and secondary diagnoses, 


the primary procedure used (if there is surgery), 
the age of the patient and the patient’s dis- 
charge status. DRG 167, for example, is an 
appendectomy without complicated principal 
diagnosis, complications, or associated illness 
for a patient under 70. 

Hospital Association Proposal 

The American Hospital Association also has 
proposed a DRG-based prospective payment 
system for Medicare, although it differs from 
the Administration’s proposal on several points, 
particularly as to how prices for each DRG 
should he determined. 

Doctor Schenken said the AMA “has some 
of the same concerns about the AHA proposal 
as it has about the Administration’s.” He added, 
however, that he saw merit in experimenting 
with the proposal. 

The AMA supports experimentation with 
prospective payment systems that create in- 
centives for hospitals to be more cost conscious, 
Doctor Schenken testified. He called upon the 
committee to authorize that the Administration’s 
proposal “and other prospective pricing pro- 
posals” be demonstrated on a limited scale in 
various states before being considered for 
national implementation. 

Quality of Care Reduced 

Doctor Schenken said that if a hospital were 
underfunded by Medicare, it would respond by 
shifting costs to other payers, deferring such 
costs as maintenance, reducing nursing and other 
essential patient care staff, and postponing or 
eliminating necessary modernization and tech- 
nological improvements, thus depriving patients 
of the highest quality of care. 

“In extreme cases, hospitals providing essen- 
tial care could be forced to close,” he said. 

He added that the AMA was concerned that 
the Administration's proposal could foster a 
two-tiered system of health care, with one level 
of care for private-pay patients and one for 
Medicare patients. 


xvi 


The West Virginia Medical Journal 




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Hal G. Gillespie, M.D. 

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Obituaries 


DANIEL N. BARBER, M. D. 

Dr. Daniel N. Barber of Charleston, Treasurer 
of the State Medical Association from 1958 to 
1965, died on February 20 in a hospital there. 
He was 85. 

A native of Charleston, he was the son of the 
late Dr. Timothy L. Barber, who founded the 
Kanawha Valley Hospital in Charleston. He was 
a member of the board of directors of the hos- 
pital, which now is located in a new building 
in Charleston. 

Doctor Barber, a general practitioner, began 
practice in 1932 in Widen I Clay County), 
moving back to Charleston after several years. 

He was graduated from West Virginia Uni- 
versity, and received his M. D. degree in 1932 
from Harvard Medical School. He interned at 
Hartford (Connecticut) Hospital. 

A veteran of World War 1, Doctor Barber was 
an honorary member of the Kanawha Medical 
Society, West Virginia State Medical Associa- 
tion and American Medical Association. 

Surviving are the widow and two sons, James 
D. Barber, Ph.D., a professor at Duke Uni- 
versity, and Timothy Barber, Charleston lawyer. 
« » • 

MAX O. OATES, M. D. 

Dr. Max 0. Oates, retired Martinsburg 
surgeon, died on February 9 at his home. He 
was 85. 

He devoted most of his adult life to the 
development and operation of City Hospital, for 
which he served as Chief Executive Officer from 
1951 until his retirement in 1976. He previously 
had been Superintendent of the hospital (1941- 
1951). 

Doctor Oates was appointed Medical Director 
of the hospital in 1972. Following retirement, he 
continued to serve as hospital Treasurer and as 
a member of the board of trustees until his death. 

Other posts held with the hospital included 
those as Chairman of the Department of Surgery, 
and President of the medical staff. 

Doctor Oates was a Past President of the 
Eastern Panhandle Medical Society, and a Fellow 
of the International College of Surgeons and the 
International Academy of Proctology. 

Born in Capon Bridge (Hampshire County), 
he received both his undergraduate and M. D. 
(1929) degrees from Johns Hopkins University. 
He interned at Johns Hopkins Hospital, and 
took his residency at Duke University Hospital. 

xviii 


Doctor Oates was an honorary member of the 
Eastern Panhandle Medical Society, West Vir- 
ginia State Medical Association and American 
Medical Association. 

Survivors include the widow; two sons, Max 
0. Oates, Jr., of Flint, Michigan, and Dr. 
Theodore K. Oates II of Rochester, New York; 
and a daughter, Mary Elizabeth Oates of 
Williamsport, Pennsylvania. 

# * * 

LEO H. T. BERNSTEIN, M. D. 

Dr. Leo H. T. Bernstein, Martinsburg internist, 
died on February 13 at his home there. He was 
64. 

Doctor Bernstein was a member of the State 
Medical Association's Council from 1978 to 
1982. 

The first internist in Martinsburg and a mem- 
ber of the Berkeley County Board of Education, 
Doctor Bernstein began practice there some 30 
years ago. 

He was a Past President of the Eastern Pan- 
handle Medical Society, and was Chief of Staff 
at City Hospital in Martinsburg. 

Born in New York City, Doctor Bernstein was 
graduated from Rutgers University in 1938 with 
a B.S. degree, received a Ph.D. in bacteriology 
in 1941 from Johns Hopkins University, and 
his M. D. degree in 1949 from the University 
of Utah. 

He interned at Salt Lake County (Utah) 
General Hospital, and took residencies at George 
Washington University Hospital in Washington, 
D. C., and at Newton Baker Veterans Administra- 
tion Medical Center in Martinsburg. 

A veteran of World War II, he was a 
Diplomate of the American Board of Internal 
Medicine. 

Doctor Bernstein was a member of the 
Eastern Panhandle Medical Society, West Vir- 
ginia State Medical Association and American 
Medical Association. 

Survivors include the widow. Dr. Jean P. 
Lucas, an internist at the Martinsburg VA Medi- 
cal Center; four sons, Shawn Bernstein of 
Washington, D. C.; Joel Bernstein of Corona 
Del Mar, California; John Bernstein of Klamath 
Falls, Oregon, and Ted Bernstein, at home; and 
one daughter, Leigh Bernstein, at home. 

* # # 

JOHN C. GODLOVE, M. D. 

Dr. John C. Godlove of Martinsburg, a 
surgeon, died on February 11 in a Washington, 
D. C.. hospital. He was 71. 

A native of Martinsburg, Doctor Godlove was 
graduated from Dickinson College in Carlisle, 

The West Virginia Medical Journal 


Pennsylvania, and received his M. D. degree in 
1944 from the University of Maryland. He took 
his postgraduate training in the Baltimore area. 

A veteran of World War II, Doctor Godlove 
was an honorary member of the Eastern Pan- 
handle Medical Society, West Virginia State 
Medical Association and American Medical As- 
sociation. 

Survivors include the widow; two daughters. 
Linda Godlove of New York City and Mrs. 
Tootie Ridenour of Williamsport (Grant 
County); one son, John C. Godlove II of Harris- 
burg, Pennsylvania, and one brother, Arnold 
L. Godlove of Hagerstown, Maryland. 

• « « 

PETER D. CRYNOCK, M. D. 

Dr. Peter D. Crynock, retired Morgantown 
general practitioner, died on February 19. He 
was 75. 

Following service with the U. S. Army Medi- 
cal Corps during World War II, Doctor Crynock 
was a company doctor at the Koppers Coal 
Company Mine at Grant Town in Marion 
County, and later was company doctor with 
Pursglove Coal Company and Christopher Coal 
Company in Monongalia County. 

After leaving mine practice, he entered pri- 
vate practice in Morgantown, and was a staff 
member of the former Vincent Pallotti Hospital 
and at Monongalia General Hospital until his 
retirement. 

Doctor Crynock, w r ho was born in Dearth. 
Pennsylvania, was graduated from West Virginia 
University, and received a Doctor of Medicine 
and Master of Surgery (M. D. C. M.) degree 
in 1935 from Dalhousie University in Halifax, 
Nova Scotia, Canada. He interned at institu- 
tions in Nova Scotia. Doctor Crynock also 
earned a degree in science from the University 
of Virginia. 

He held life memberships in the U. S. Military 
Surgeons and the U. S. World Medical Associa- 
tion; was a member of the Dalhousie Alumni 
Association and its Emeritus Club; held a fel- 
lowship in the Royal Society of Health, Patron 
of her Majesty the Queen, in London, England; 
and was an honorary member of the Monongalia 
County Medical Society, West Virginia State 
Medical Association and American Medical As- 
sociation. 

Survivors include the widow; one brother, 
John E. Crynock of Morgantown, and five sisters, 
Anna Crynock, Mary Sypolt, Susan Crynock and 
Kathryn Crynock, all of Morgantown, and Emily 
Crynock of Chicago. 


County Societies 


McDowell 

The McDowell County Medical Society met 
on February 9 at Stevens Clinic Hospital in 
Welch. 

The American Medical Association video 
cassette program on dizziness was presented. 

The meeting was preceded by a social hour 
and covered-dish dinner provided by the 
Auxiliary. — John S. Cook, M. D., Secretary. 

« # « 


FAYETTE 

The Fayette County Medical Society met on 
February 2 at the Plateau Medical Center in 
Oak Hill. 

The guest speaker was Dr. Hassan Amjad of 
Beckley. His topic was “Cancer of the Lung.” 
— Serafino S. Maducdoc, Jr., M. D., Secretary- 
Treasurer. 


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The West Virginia Medical Journal 

Vol. 79, No. 5 May, 1983 

Hypokalemic Myopathy In Hyperemesis Gravidarum: 
Its Historical Significance* 


JACK E. RIGGS, M. D. 

Department of Neurology, West Virginia University 
School of Medicine, Morgantown 

ROBERT C. GRIGGS, M. D. 

Department of Neurology, University of Rochester 
School of Medicine and Dentistry, Rochester, 

New York 

LUDWIG GUTMANN, M. D. 

Department of Neurology, WVU School of Medicine 


The occurrence of hypokalemic myopathy in 
a iv oman with hyperemesis gravidarum is re- 
ported. Although previously unrecognized , 
hypokalemic myopathy may have been a rela- 
tively common cause of weakness in some cases 
of hyperemesis gravidarum. 

■\J"USCLE weakness complicating pregnancy was 
a well-recognized occurrence during the 
nineteenth century. In von Hosslin’s review of 
494 such cases the causes of weakness included 
trauma, infection, focal neuropathies, and 
polyneuropathies. 1 The polyneuropathy develop- 
ing during pregnancy was referred to as the 
polyneuritis of pregnancy, accounting for ap- 
proximately 10 per cent of the cases in von 
Hosslin's review . 2 

As early as 1889, an association was noted 
between hyperemesis gravidarum and the 
polyneuritis of pregnancy, 3 and this subsequently 
was firmly established. 2 Since hyperemesis 
gravidarum initially was thought to represent 
a toxic manifestation of pregnancy, it was 

“Presented in part at the 34th Annual Meeting of the 
American Academy of Neurology, May 1, 1982, Wash- 
ington, D. C. 


hypothesized that the polyneuritis of pregnancy 
had a similar etiology. 2 However, due to patho- 
logical and clinical similarities, the polyneuritis 
of pregnancy has been considered a nutritional- 
deficiency polyneuropathy since the 1930s. 46 
In some cases of the polyneuritis of pregnancy, 
however, sensory abnormalities and decreased 
reflexes were conspicuously absent, and a much 
more rapid resolution of motor weakness 
occurred following abatement of the hyperemesis 
than would have been expected with a neuro- 
pathy. 2 This suggests that in at least some cases 
of hyperemesis gravidarum there may have been 
a mechanism of motor weakness other than 
polyneuropathy. 

We now report a case which may shed some 
retrospective insight into the association between 
motor weakness and hyperemesis gravidarum. 

Case Report 

A 27-year-old. gravida 4, para 1, abortus 2, 
four-month pregnant woman was referred for 
neuromuscular evaluation because of progressive 
muscle weakness and an elevated creatine kinase 
(CK - 1156 IU/ml, nl 7-89 ). Previous medical 
history w r as unremarkable. The only medication 
on admission was a daily vitamin tablet. 

Her pregnancy had been complicated by per- 
sistent nausea and vomiting for three months. 
She had been vomiting 10 to 12 times per day 
during the two weeks preceding her hospital 
admission. Four weeks before admission, she 
noted tenderness of her thigh muscles and diffi- 
culty climbing stairs and lifting her arms above 
her head. She became so weak that her husband 


May, 1983, Vol. 79, No. 5 


95 



Figure. Biceps muscle. Composite demonstrating 
rare isolated vacuolated muscle fibers (modified 
Gomori trichrome, X126). 


had to carry her about their home. She had 
lost 13 pounds during her pregnancy. There 
was no history of fever, joint symptoms, skin 
rash, or dark urine. 

On admission she was very thin. Her abdomen 
was soft and the uterus was palpable below the 
umbilicus. Bowel sounds were present. General 
examination was otherwise unremarkable. Muscle 
hulk was slender and tone was normal. Her 
thigh muscles were tender to palpation. She 
was unable to lift her head off the bed when 
supine, squat, or step up onto an eight-inch stool. 
Muscle strength ( Medical Research Council 
Scale) was grade 4- to 4 proximally except for 
the neck flexors (grade 2) and hip flexors 
I grade 3). The remainder of the neurologic 
examination, including reflexes, was normal. 

Laboratory Studies 

Admission laboratory studies showed: K - 1.9 
mEq/L, Na - 140 mEq/L, CO? - 25 mEq/L. 
Cl - 103 mEq/L, BUN - 5 mg/dl, Hct - 31 per 
cent, CK - 1580 IU/L (MB fraction negative), 
LDH - 269 IU/L (nl 100-225), and AST - 116 
IU/L (nl 7-40). Urine was negative for 
hemoglobin and myoglobin. Thyroid, renal. 


adrenal, liver, immunologic, and other electro- 
lyte studies were normal. Electrocardiogram 
showed changes consistent with hypokalemia. 

Treatment and Results 

After admission, 200 mEq of oral potassium 
chloride (K-lyte/Cl R ) was administered over 
eight hours, at which time serum K had risen 
to 3.3 mEq/L. Her strength improved rapidly 
during the first two days after admission. EMG 
studies two days after admission were normal. 
Left biceps muscle biopsy done three days 
after admission demonstrated a mild vacuolar 
myopathy (Figure). Eight days after admission. 
CK was 21 IU/L. One month after admission 
her strength had returned to normal. Her vomit- 
ing ceased immediately after the hypokalemia 
was corrected and did not recur (see Table for 
clinical and laboratory summary). The patient 
gave birth to a normal baby girl five months 
after admission. A diagnosis of hypokalemic 
myopathy complicating hyperemesis gravidarum 
was made. 

Discussion 

In 1951. Bergquist first reported the occur- 
rence of hypokalemia in hyperemesis gravidarum 
and speculated that potassium deficiency was 
responsible for the associated muscle weakness 
in his case.' He also suggested that motor weak- 
ness present in some previously reported cases 
of the polyneuritis of pregnancy may actually 
have been related to potassium deficiency pro- 
duced by the persistent vomiting in hyperemesis 
gravidarum." Appearing soon were two ad- 
ditional reports also describing muscle weakness 
in hyperemesis gravidarum with associated 
hypokalemia. 8,9 In these cases, rapid improve- 
ment of muscle strength followed correction of 
the hypokalemia. 8 ' 9 In 1955, significant hypo- 
kalemia was reported in nine of 10 women with 
hyperemesis gravidarum, suggesting that hypo- 
kalemia is usually present in hyperemesis 
gravidarum. 10 


TABLE 


Clinical and Laboratory Summary 



CPK (IU/L), nl 7-89 

K(mEg/L), nl 3. 5-4. 5 

Vomiting 

Weakness 

1 day before admission 

1156 

2.0 

present 

severe 

Admission 

1580 

1.9 

present 

severe 

6 hours after admission 

- 

1.7 

present 

severe 

11 horns after admission 

- 

3.3 

absent 

moderate 

2 days after admission 

- 

3.6 

absent 

moderate 

4 days after admission 

202 

3.8 

absent 

mild 

8 days after admission 

21 

3.8 

absent 

minimal 

1 month after admission 

- 

- 

absent 

none 


96 


The West Virginia Medical Journal 


Although hypokalemia has been associated 
with hyperemesis gravidarum, a specific my- 
opathy in hyperemesis gravidarum has not been 
previously identified as a cause of weakness. 
Hypokalemic myopathy in man initially was 
reported in 1955. the same year as the last report 
to note specifically hypokalemia in hyperemesis 
gravidarum. 10 This coincidental disappearance 
of motor weakness from the hyperemesis 
gravidarum literature and the initial description 
of hypokalemic myopathy presumably is related 
to improved obstetric fluid, electrolyte, and 
nutritional management. This case provides the 
first documentation that hypokalemic myopathy, 
in addition to nutritional neuropathies, may be 
a cause of muscle weakness in hyperemesis 
gravidarum. Hyperemesis gravidarum previously 
has not been associated with hypokalemic 
myopathy. 12 

Due to the incidence of hyperemesis gravi- 
darum I about one case per 1.000 births) 13 and 
the frequent significant hypokalemia in hypere- 
mesis gravidarum, 10 hyperemesis gravidarum 
may have been a relatively common, although 
previously unrecognized, cause of hypokalemic 
myopathy. Conversely, hypokalemic myopathy 
may have been a relatively common, although 
previously unrecognized, cause of weakness in 
some cases of hyperemesis gravidarum. 

Generic drug listing : potassium chloride 

iK-lyte/Cl R ). 


References 

1. von Hosslin R: Die schwangerschaftslahmungen 

der mutter. Arch fur Psych Nervenkrank 1904; 38:730- 
861 & 1905; 40:445-576. 

2. Berkwitz NJ, Lufkin NH: Toxic neuronitis of 

pregnancy: A clinicopathological report. Surg Gynecol 
Ohstet 1932; 54:743-757. 

3. Whitfield DW: Peripheral neuritis due to the 

vomiting of pregnancy. Lancet 1889; 1:627-628. 

4. Strauss MB, McDonald WJ: Polyneuritis of preg- 
nancv: A dietary deficiency disorder. JAMA 1933; 100: 
1320-1323. 

5. Luikart R: Avitaminosis as a likely etiologic factor 
in polyneuronitis complicating pregnane)', with the re- 
port of a case. Am J Ohstet Gynecol 1933; 25:810-815. 

6. Theobald GW : Neuritis in pregnancy successfully 
treated with vitamin Bl. Lancet 1936; 1:834-837. 

7. Bergquist N: Potassium deficiency in hvperemesis 
gravidarum. Acta Ohstet Gynecol Scand 1951; 30:428- 
438. 

8. Lans HS, Gollin HA, Daro AF, Nora E: Hypo- 
kalemia due to persistent vomiting during pregnancy. 
JAMA 1953; 153:1012-1015. 

9. Romney SL, Merrill JP, Reid DE: Alterations of 
potassium metabolism in pregnancy. Am J Ohstet 
Gynecol 1954; 68:119-130. 

10. Fitzgerald JPB: Potassium depletion and replace- 
ment in hyperemesis. New Zealand Med J 1955; 54:36- 
50. 

11. Achor RWP, Smith LA: Nutritional deficiency 

syndrome with diarrhea resulting in hypopotassemia, 
muscle degeneration and renal insufficiency: Report of 
case with recovery. Mayo Clin Proc 1955; 30:207-215. 

12. Penn AS: Myoglobin and myoglobinuria, in 

Vinken PJ, Bruyn GW (eds): Handbook of Clinical 

Neurology , Amsterdam, Elsevier/North-Holland Biomedi- 
cal Press, 1979; 41:259-285. 

13. Fairweather DVI: Nausea and vomiting during 
pregnancy. Ohstet Gynecol Annu 1978; 9:91-105. 



i/i 


3 

- 3 

5 


May, 1983, Vol. 79, No. 5 


97 




Diagnosis And Treatment Of Alzheimer's Disease 


M. K. HASAN, M. D. 

Psychiatrist, Division of Behavioral Sciences and Psy- 
chiatry, Beckletj Appalachian Regional Hospital, Beck- 
ley, West Virginia; and Assistant Clinical Professor, 
Department of Psychiatry, Marshall University School 
of Medicine, Huntington, West Virginia 

NANCY L. SLACK, A.C.S.W. 

Social Worker, Division of Behavioral Sciences and 
Psychiatry, Beckletj Appalachian Regional Hospital 

ROGER P. MOONEY, M.A. 

Clinical Psychologist, Division of Behavioral Sciences 
and Psychiatry, Beckletj Appalachian Regional Hospital 


By the year 2030, 25 million of the estimated 
55 million elderly will be 75 years of age and 
older. The major health problem facing this 
group is dementia. If this trend continues, 
dementia will be third only to cancer and heart 
disease as a cause of mortality and morbidity in 
this group. Approximately four million people 
65 and older have dementia of the Alzheimer's 
type. 

In this paper, the features of Alzheimer's 
disease and the various diagnostic tools are dis- 
cussed. The authors compare the disease process 
with the depressive illness, keeping in mind that 
dementia is a clinical diagnosis. Recommenda- 
tions for maintenance and treatment are pro- 
vided. 

Tr is estimated that 11 per cent (25 million) 
of the U. S. population is over 65 years of 
age; however, this group accounts for 30 per cent 
of all personal health care spending and 55 per 
cent of all federal health dollars. It is further 
estimated that of the 287 billion dollars spent 
annually for personal health care, approximately 
75 billion is for the elderly, especially those 75 
and over. This, by far, is the most rapidly 
growing segment of the population. By the year 
2030, 25 million of the estimated 55 million 
elderly will be 75 and older. 

While growth of this segment is taking place 
at an amazing rate, knowledge of the aging 
process, including the diagnosis, ramifications 
and treatment of its diseases, is being assimilated 
all too slowly. “Ageism," prejudice against the 
elderly, is common and rampant among all pro- 
fessionals including physicians. “Ageism" con- 
tributes to the frustration that “nothing can be 
done” or “nothing should be done." Treatment 
is seen as an “unworthy investment of time and 
effort. These attitudes often encourage hostility, 
paranoia, depression, abandonment and indif- 

98 


ference, and have been linked to “familial 
elderly abuse.” This is a sinister situation which 
poses a serious dilemma to care providers who 
have turned increasingly to the family as “the 
last line of defense in the care of the aged." 

The country's nursing home expenditures have 
been rising at an annual rate of 16 per cent. 
Today, with 1.3 million people in nursing homes, 
the spending level is nearing $22 billion; by 
1990. it is estimated to reach $75 billion. By 
that time nearly 10.300 geriatricians will be 
needed as consultants and, in complex cases, as 
primary care practitioners. According to a 1977 
American Medical Association survey, fewer 
than 700 physicians identified themselves as 
having a primary, secondary, or tertiary specialty 
in geriatrics. 

Research Lags 

Fifteen per cent of people age 65 years and 
over have some form of psychiatric impairment 
and. of these, three per cent require institu- 
tionalization. Five per cent of people age 65 
and older, approximately four million, have 
dementia of the Alzheimer's type, a disorder 
that is marked by progressive mental deteriora- 
tion of memory and judgment. Of these, one 
million are so severely affected that they cannot 
manage themselves. Despite the severity of the 
problem, only $16 million was spent on dementia 
research last year, as compared to the $22 billion 
spent in nursing homes. 

Alzheimer’s disease, a form of primary 
neuronal degeneration, was first described by 
Alzheimer, in 1907, in a 51-year-old female. 
The female died four and one half years later, 
and the classical histopathology was determined. 
It is the most common form of irreversible 
dementia, accounting for 50 to 70 per cent, as 
opposed to multi-infarct dementia, which repre- 
sents 15 to 20 per cent. 

Early diagnosis of Alzheimer’s is essential and 
of paramount importance because treatment 
differs. I nfortunately. referral is often too late 
or delayed; consequently, the illness has pro- 
gressed too far for any improvement. This has 
a detrimental effect on the family and their 
morale, as well as on the community. In turn, 
feelings of rejection in the patient and his 
further deterioration occur due to poor manage- 
ment. Paradoxically, it has been shown that 
differentiation is easier in the earlier stages of 
the disease, thereby allowing more humane, 

The West Virginia Medical Journal 




compassionate, and cost-effective treatment, pre- 
ferably at home by caring relatives and 
neighbors. 

In this paper, the authors discuss the clinical 
features of Alzheimer’s disease, the various 
diagnostic tools, and compare the disease process 
with the depressive illness. The authors also 
provide recommendations for maintenance and 
treatment. 

Diagnosis 


To establish a diagnosis of Alzheimer’s disease, 
a biopsychologieal. social approach which entails 
a life history of the patient is necessary. A 
thorough physical examination, including a 
detailed drug history, is essential. The following 
laboratory examinations are recommended in 
all cases of suspected Alzheimer’s disease: 


— CBC 

— Electrolytes 

— SMA 12 

— EKG 

— Serology 

— Urinalysis 

— Ti 


— Dexamethasone Suppression 
Test (a level of over 6 /rg/dl of 
serum cortisol is indicative of a 
depressive illness) 

—Serum Magnesium (as excessive 
use of laxatives or antacids can 
lead to magnesium toxicity) 


— EEG (if the EEG appears worse 
than the mental state, then 
dementia is likely to be 
secondary rather than indicative 

— Serum Aluminum 0 f Alzheimer’s disease) 

— Psychological Tests _ 0ccult Blood Stool x 3 days (to 

Chest X-ray detect occult cancers, especially 

— CT Scan of the colon) 


— TSH 

— Serum B12 

— Folic Acid 


A thorough evaluation may be expensive on 
a short-term basis; however, it is cheaper in the 
long run, especially if an early diagnosis reveals 
a treatable condition. It is estimated that 20 to 
25 per cent of the patients diagnosed as having 
organic brain syndrome ( OBS ) have a causative 


factor which is treatable, resulting in ameliora- 
tion of the symptoms. Tests can he completed 
on an outpatient basis. 

Another essential diagnosis to be included 
and excluded in all cases of dementia is depres- 
sion, which can mask chronic OBS. In our 
practice we assume that all patients suffering 
from dementia have depression unless proven 
otherwise. When the dementia is accompanied 
by psychomotor retardation, the possibility of 
depression or multi-infarct dementia should he 
explored. With depression, the onset is sudden 
and the patient is better at night. The depressed 
patient tends to surrender to the disability, 
whereas the demented patient fights it. When 
depression is treated successfully, immense 
gratification and reward are by-products to all 
concerned. 

Kiloh 1 emphasized the danger of relying on 
psychological testing for diagnostic purposes. 
Some of his patients on psychometric testing 
showed alterations typical of organic deteriora- 
tion: normal restitution was attained after treat- 
ment of depression. Similarly, CT scans showing 
cerebral atrophy could not be judged as a sign 
of dementia. Cerebral atrophy is ubiquitous 
after the age of 50, even in intellectually intact 
persons. Dementia is a clinical diagnosis, and 
a holistic approach is essential. The single best 
diagnostic tool is the mental status. 

After the diagnosis of Alzheimer’s disease or 
dementia has been made, the family is faced 
with several decisions. If the person has been 
living alone, can he or she continue in that 
situation? Another frequent uncertainty is the 
ability of family members to care for the patient 


TABLE 1 

Comparison of the Clinical Features of Alzheimer’s Disease with Other Organic Brain Syndromes 


A. Early Phase 

Alzheimer’s Disease 

Non- Alzheimer’s 
Disease 

I. Memory Loss 

Early, insidious, patient becomes less spontaneous, is irri- 
table, seeks and prefers familiar surroundings, may go 
unnoticed by relatives, covers up his loss, may show 
“catastrophic reaction’’ 

Late 

II. Precipitating Factors 

May be present during bereavement, children leaving 
home, etc.— any situations involving interruption of the 
patient’s daily routine 

Less Often 

III. Apraxia 

Early, but after memory loss, may present as dressing 
apraxia or inability to arrange objects in space 

Late 

B. Intermediate Phase 

Emotional lability, shallow affect, irritability' and insensi- 
bility, increasingly self-absorbed, speech may be affected, 
needs management in specialized services, as banking, etc. 

Also Seen Here 

C. Late Phase 

Market changes in personality, confabulation, incontinence, 
preservation of social competence, hematological signs 
present, may show psychotic features and neurological 
deficits 

Early 


May, 1983, Vol. 79, No. 5 


99 


TABLE 2 

Comparison of the Clinical Features and the Aspects of Treatment of Depression and Dementia. 



Depression 

Dementia 

Age 

Earlier 

Late, usually after 75 

Onset 

Recent, rapid, following a precipitating 
event, may regress and may become vege- 
tative 

Insidious, no broad linkage to a precipita- 
ting event, happier and active 

Past History 

Of depression with behavior disturbance 

Absent 

Family History 

Of depression 

Of dementia 

Memory Loss 

Complains bitterly of memory loss which is 
generalized, poor concentration, puts no ef- 
fort in answers, gives in easily and says, “I 
don’t know.” 

Rarely complains, covers up memory loss 

Affect 

Pervasive, depressed 

Emotional lability, appears happier in gen- 
eral, shallow, may show depressive content 
in early part of the disease 

Treatment 

DST, trial of antidepressants (adequate dose 
for 3-6 weeks), psychotherapy (especially 
cognitive therapy) 

Supportive psychotherapy involving the indi- 
vidual, family and significant others 

Miscellaneous 

Family less tolerant of global disinterest 

Family tolerant of forgetfulness and often 
say, “It’s his age.” 


Other features of depressive illness present 

Absent 


Seek treatment earlier 

Avoid treatment 


in their homes. These questions need to be dis- 
cussed with those who know the patient well. 
The primary care physician and the family are 
in the best position to deal with these concerns. 

Recommendations 

At the present time there are no hard and fast 
rules on how to care for the patient, only recom- 
mendations. In each case consideration should 
be given to the individual needs of the people 
who are involved and the practicality of the 
situation. 

A. Medical 

1. The primary care physician should 
avoid polypharmacy and schedule 
periodic physical assessments. 

2. Medication needs to be kept to a 
minimum, and nutrition, hydration 
and constipation need to be monitored. 

3. The presence of depression as a 
psychiatric syndrome as well as other 
psychiatric syndromes should be thor- 
oughly evaluated. 

4. The primary care physician needs to 
attend to other physical or mental 
disorders. 

5. The use of neuroleptic drugs and. 
in some instances, electro-convulsive 


therapy, may eliminate the depressive 
features. Antidepressants with the 
least anticholinergic side effects are 
recommended in low doses. 

6. Cerebral vasodilators are valueless. 

7. Hydergine, an ergot alkaloid, has been 
shown to be beneficial in a small num- 
ber of selected cases, especially in the 
early phase. 

8. Lecithin, choline, and physostigmine 
have shown controversial and un- 
impressive results. 

B. Psychosocial 

1. In the early stages of the disease, the 
patient may be able to continue his 
personal hygiene as usual: however, in 
the middle and latter stages, he may 
need assistance. Clothing choices 
should be kept to a minimum, and old 
clothing or clothing of the wrong size 
should be discarded. Allow the patient 
to do as much of his personal hygiene 
as possible, and assist when necessary. 

2. Incontinence often is frustrating to the 
family. Initially, loss of bladder con- 
trol may occur only occasionally; how- 
ever. as the disease progresses it may 
become more frequent. Regular at- 


100 


The West Virginia Medical Journal 


tendance to the bathroom, restricting 
fluids in the evening, and going to 
the bathroom before bedtime should 
be done routinely. When needed, 
adult-size diapers may be used. Avoid 
fecal impaction by regular toilet- 
training, well-balanced meals with high 
fiber content, prune juice, and Meta- 
mucil.® Fecal impaction can be a 
cause of confusion. 

3. Regular sleep hygiene should be en- 
couraged. Daytime napping and sleep- 
ing aids should be avoided. Where 
needed, use L-Tryptophan (a natural 
amino acid present in milk, cheese, 
fish, etc.) in a dose of 1000-1500 mg., 
given 1-2 hours prior to bedtime. 

4. Regular exercise when possible (e.g., 
a daily walk with supervision) is 
strongly advised. 

5. As the disease progresses, the patient 
becomes increasingly forgetful and 
shows signs of memory impairment, 
especially for recent events. He may 
need gentle reminders to do things he 
previously did routinely. Articles such 
as glasses and dentures may become 
misplaced. The family may need to 
take the responsibility of placing the 
dentures and glasses in a certain place 
at night and giving them to the patient 
in the morning. Orienting the patient 
to time, place and the other person (s) 
present also will reduce stress. This 
can be done, for example, by saying, 
“We will now go into the kitchen for 
lunch. Visitors, including family 
members, should be introduced by 
name. 

6. In many communities there are volun- 
tary groups (The Alzheimer Society) 
whose members share their common 
experiences in caring for persons with 
Alzheimer’s disease. The group pro- 
vides information on new advances 
made in research, and services that are 
available; however, the most important 
aspect of the group is that of emotional 
support for its members. It is the 
common sharing that boosts the mem- 
bers’ morale. 

Summary 

WTiereas the life expectation for patients suf- 
fering from dementia used to be two to three 
years, advancements in medicine now have ex- 


tended it to 10 years. Dementia has become a 
major health problems and, if the trend continues, 
will be third only to cancer and heart disease 
as a cause of mortality and morbidity by the 
year 2000. 

Economists may question the cost-effectiveness 
of providing expensive and demanding services 
to those who will never be productive members 
of society again, but health care cannot be 
measured in dollars alone. The quality of life 
is important; and, if we can improve this by 
rehabilitative and diversional facilities, the 
authors believe the money is well spent. Un- 
fortunately, in the authors’ opinion, some of the 
blame for inadequate care for the elderly can 
be leveled at the U. S. Health Care Financing 
Administration, which controls Medicare and 
emphasizes “cost containment’’ above all else. 
Many insurance carriers conform to the guide- 
lines of Medicare. Although Medicare re- 
imburses medical and surgical services at 80 
per cent of all customary and reasonable fees with 
no yearly maximum, it reimburses only 50 per 
cent and up to $250 per year for psychiatric 
consultation and care. This has resulted in 
inappropriate use and overuse of psychotropics 
with some deleterious effect. This may appear 
cheaper in the short run, but the resulting in- 
crease in morbidity and mortality adds signifi- 
cantly to long-term care, to say nothing about 
the tragic waste of human potential. 

New Programs Will Be Needed 

Research into the cause and treatment of 
Alzheimer’s disease and similar diseases is being 
conducted throughout the country. Ultimately, 
prevention and treatment will be the answer. 
Until this can be accomplished, however, the 
care and management of a person with these 
diseases will be a major concern of families and 
health care providers. Health and social pro- 
grams will have to be developed and expanded 
to meet these needs. 

Presently, there are several programs being 
utilized throughout the country which deserve 
further attention. Day care for the elderly is 
similar to the day care programs for children; 
however, the providers are specifically trained in 
the needs of geriatric persons. This allows the 
family members to continue employment while 
being reassured that the elderly relative is 
being looked after. Also, home care programs 
and tax breaks are being explored to provide 
financial incentive to the family members for 
keeping elderly persons at home. Both of these 
programs, and others, should be further de- 
veloped, and the need for them documented. 


May, 1983, Vol. 79, No. 5 


101 


Each concerned person has a right, and some- 
what of a responsibility, to let the policy 
makers know that the need exists. Not until 
enough people do so will improved and new 
programs become a reality. 

References 

1. Kiloh LG: Pseudodementia. Acfo Psychiatr Scand 
1961; 37:336-351. 

2. Larsson T, Sjogren T, Jacobson G: Senile de- 
mentia: A clinical, sociomedical and genetic study. Acta 
Psychiatr Scand 1963; Suppl 39. 

3. Perl DP, Brody AR: Alzheimer’s disease: X-ray 
spectrometric evidence of aluminum accumulating in 
neurofibrillary tanglebearing neurons. Science 1980; 208: 
297-299. 

4. Schneck MK, Reisburg B, Ferris SH: An overview 
of current concepts of Alzheimer’s disease. Am J Psy- 
chiatry 1982; 139:165-173. 


5. Wells CE: Management of dementia in congenital 
and acquired cognitive disorders, in Katzman R (ed): 
Dementia , New York, Raven Press, 1979, p 281. 

6. Acute confusion, depression are misdiagnosed as 
senile dementia. Clin Psychiatry News , March, 1982, 
p 31. 

7. Alzheimer’s psychometric deficits correlate with 
brain changes. Clin Psychiatry News , March, 1982, p 1. 

8. Brain changes correlate with psychometric loss in 
dementia. Clin Psychiatry News, March, 1982, p 26. 

9. Clinical acumen ultimate basis for subcortical de- 
mentia diagnosis. Clin Psychiatry News, March, 1982, 

P 7- 

10. Dementia major health problem with mortality 
decline in elderly. Clin Psychiatry News, March, 1982, 
p 15. 

11. National Center for Health Statistics: The pro- 
jection of the population of the United States, 1975-2050, 
in Census Bureau Current Population Reports Series, 601. 
Washington, DC, US Government Printing Office, 1975, 
p 25. 


Manuscript Information 

Manuscripts to be presented for publication in The West Virginia Medical 
Journal should be typewritten, triple-spaced, on one side only of firm (no 
onion skin or flimsy), standard letter sized ( 8 V 2 by 11 in.) white paper. 
Wide margins (at least 114 in. on left) should be left free of typing. On 
the first or title page should be shown the title of the article, the name (or 
names) of the author, and his degrees. Pages should be numbered consecu- 
tively, the page number being shown in the right upper corner along with 
the surname of the author. 

Where reference is made to generically-designated drugs, the first such 
reference must be followed by parentheses containing the most commonly 
known trade-name drug of that designation. In addition, a listing of all generic 
drugs mentioned in the article, with their trade-name equivalents, should 
appear at the end of the article. 

A short abstract summarizing the manuscript should be included. This 
should be typed in double space on a separate page. 

Authors are requested to submit a carbon copy with the original. 

Illustrations should be numbered and their approximate locations shown 
in the text. Each should be identified by placing on its back the author’s 
name, its number and an indication of its “top.” Drawings and charts in- 
tended for reproduction should be done in black (India) ink on pure white. 
Photographs should be on glossy paper and minimum of about 5 by 7 in. 
in size. Cost of printing black and white photos in excess of 4 will be billed to 
author, and no more than 25 references will be published free of charge 
to the author. A legend should be provided for each illustration and, preferably, 
attached to it. 

All scientific material appearing in The Journal is reviewed by the 
Editorial Board. Manuscripts should be mailed to The Editor, West Virginia 
Medical Journal, Box 1031, Charleston, W. Va. 25324. 


102 


The West Virginia Medical Journal 




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THE ‘COST CONTAINMENT' (?) BILL 


T his month, I intended to discuss involve- 
ment, but after visiting Greenbrier Val- 
ley and Wetzel County Medical Societies, 
there were many questions on the so-called 
hospital cost containment bill. I would like 
to address it this month, with involvement 
to come in the future. 

We must first realize “cost containment” 
is a misnomer for the legislation enacted in 
the last 16 minutes of the 60th day of the 
Legislative Session. The bill actually estab- 
lishes a three-member authority to regulate 
and limit rates hospitals can charge but does 
not address any costs incurred by hospitals. 
Interestingly enough, the funding for this bill 
is borne by the hospitals themselves, thereby 
increasing their costs. This is reminiscent of 
medieval times when a condemned person 
was forced to pay for his own executioner in 
order to assure a swift and merciful death. 

Before this authority has even met, hos- 
pital rates have been frozen at the level of 
February 1, 1983, regardless of any increases 
in costs for goods and services hospitals may 
have acquired since that time. In addition, 
the bill mandates a 12-per cent cap on in- 
creases in gross revenue for hospitals. Any 
funds in excess of this 12 per cent will go to 
the board itself with no indication as to how 
these monies are to be spent. Unfortunately, 
this provision is retroactive to the hospital’s 
last reporting period. This means that if the 
hospital’s fiscal year ended prior to the 
effective date of this legislation, then the 12- 
per cent cap could be on 1981 or 1982 
revenues. 

Many hospitals already may have exceeded 
those older limits through expanded services 
and offering improved care. This new legis- 
lation does not recognize these exceptions. 
The money is due now. This appears to me 
to be confiscation, not even an acceptable 
form of taxation. I am unaware of any other 
industry in our state which must turn over to 
a state-appointed bureaucracy a percentage 
of its gross revenue, not its profits. 

Perhaps, if this legislation sets a precedent, 
the State Highway Department and the De- 


partment of Motor Vehicles will set the same 
sort of cap on the revenues of the automobile 
dealers in our state and, by confiscating their 
money, could obtain the funding to fix the 
roads. In this example, one thing is for sure: 
there would be a lot fewer automobiles using 
those roads. 

The bill also allows the rate regulators to 
have jurisdiction over the professional 
charges of a hospital-based physician under 
contract to a hospital. I do not feel that it 
would be advantageous to our attempts to 
attract top-flight radiologists, anesthesi- 
ologists, pathologists and emergency room 
physicians to West Virginia to have to inform 
them that their professional fees will be set 
in advance by a bureaucratic agency of the 
state government. Indeed, I wonder if we 
can retain some of the ones we now have. 

As you have probably noticed, I do not like 
any part of this law. The original intent may 
have been good, but I feel it was an ill- 
conceived and politically motivated act 
which was passed in the closing moments of 
the session by political pressure, and possibly 
was poorly understood by a majority of the 
members of the legislature. I feel it will be 
detrimental to the quality of medical care 
of our citizens, as the regulators are given the 
authority to determine the “quality of care” 
without any representation or any input 
from the medical profession. 

I fear in the future this will be considered 
the “Mandolidis decision” for the health care 
industry in our state. Down the road a few 
years we will need the same type of bail-out 
to recover from its effects as industry in our 
state received this year. Unfortunately, by 
then it may be far too late for many of our 
hospitals and physicians. 


n 


/ 



Ql 




Harry Shannon, M. D., President 
West Virginia State Medical Association 


104 


The West Virginia Medical Journal 


The West Virginia ttedical Journal 

Editorials 

The Publication Committee is not responsible for the authenticity of opinion or statements made by authors or 
in communications submitted to this Journal for publication. The author shall be held entirely responsible. 
Editorials printed in The Journal do not necessarily reflect the official position of the West Virginia State 
AJ\edical Association. 


Now that we all know all about DRGs ( see 
editorial in April issue of The Journal l, let's 
talk about some interesting related issues. 
Diagnostic Related Groups are the basis for a 
prospective method of hospital payment for 
Medicare patients. 

We have mentioned that hospital admini- 
strators are worried about DRGs. They feel 
vulnerable to manipulation by staff members who 
might threaten to run up 
MORE ON DRGs costs if certain whims and 
desires are not satisfied. Ad- 
ministrative control over diagnostic enthusiasm 
is simply not present under our current system. 
As a matter of fact, it would have been silly for 
hospital administrators to even think of such 
control as long as no one questioned payment 
on the basis of cost. 

Things are different now. A cost basis of 
payment is out because it leads to cost escalation. 
Prospective payment is in because costs can be 
budgeted and controlled. 

How to get a handle on control of clinical 
costs is the problem now facing hospital admini- 
strators. One method is through utilization 
review. This has been tried under the old cost 
basis payment method and found to be of limited 
use. It will be tried again with more vigor. 
Another way is somehow to close and exercise 
more control over medical staffs. Surplus num- 
bers of physicians make this an attractive pos- 
sibility but altering medical staff bylaws to 
accomplish it might be difficult. 

A sure way to control clinical costs is to have 
salaried physicians. They make money or they 
are fired. Have you noticed hospitals in your 
area employing physicians in newly created 
positions recently? 

There is absolutely no question that the sur- 
vival of some hospitals is at issue. With or with- 
out the wholehearted cooperation of staff physi- 
cians, some hospitals are likely to go under as 
a result of financial pressures brought to bear 
by DRG prospective pricing. 


What if too many hospitals go under? What 
if three hospitals in Charleston go under, or two 
in Wheeling or two in Huntington? What would 
be the medical consequences of such a tragedy? 
What would he the political consequences? 

These are not idle questions. It is being pro- 
posed that great risks be taken with our medical 
care system. Where is the safety net in this high 
wire act? Where are the life rafts if this ship 
won’t float? 

Prospective hospital payment plans using 
DRGs hold great promise. We do not know 
whether any plan yet proposed will work. The 
concept merits testing but not full support. Not 
yet. 


We have all heard tales about how this or 
that health care system is good or bad. The 
tale is usually followed by an important excep- 
tion, such as “the system is poor, but my doctor 
is good." There is no health care system that 
pleases all, nor will there 
THE PATIENT, ever be. The marketplace 

OR THE SYSTEM? varies within the political 
climate, and a framework is 
produced that tries to serve the common good 
To do what is best for society as a whole some- 
times masquerades as being best for each indi- 
vidual. This leads us to many irreconciliable 
differences. A system that sacrifices individual 
needs to more global needs cannot honestly and 
consistently be represented as best serving my 
needs or yours. 

In such a climate, we try to serve a patient 
whose individual needs must he paramount. Yet 
our services must be tempered by the law, 
the government, third-party payers, hospital 
facilities and, indeed, the whole social fabric. 
We commit ourselves to offering the best 
diagnostic and therapeutic options for an indi- 
vidual patient regardless of time or cost. Then 
we must modify our suggestions based on some 
larger perspective. The thread is lost in the 


May, 1983, Vol. 79, No. 5 


105 



tapestry. Are we fooling ourselves? Are we 
fooling our patients? Or are w T e all being fooled? 

There is not one system so far and away 
above all others that all others should cease. 
Freedom of choice is a fine idea, but let it be 
made clear that a commitment to one or another 
health care system is not necessarily a commit- 
ment to better health care for every individual. 

That one individual will still depend upon 
other individuals for proper care. The health 
care system serves the people. We as physicians 
serve the patient. — Stephen H . Franklin , M.D., 
in the Delaware Medical Journal. 



I have read with special interest the article by Parkin- 
son and Nerhood ["Special Article: Emergency Maternal 
Transfer: An Ounce of Prevention for West Virginia 

Newborns,” by Rosalind Parkinson, M. A.; and Robert C, 
Nerhood, M. D., The Journal, January, 1983, Page 9] and 
find several points to be either inaccurate or possibly in- 
appropriately interpreted. 

1. Based on the illustration presented in the article, 
the present accelerated (if any) decline in infant mortality 
began in the 60s, long before the organized effort toward 
regionalization. It is not clear in the literature when or 
why this trend began but it is clear that the increased 
infant survival is related to multiple factors of which 
the collaborative efforts to regionalize perinatal care is 
only a single factor. The statement, “Much of the in- 
creased infant survival is associated with collaborative 
efforts to regionalize perinatal intensive care on a state- 
wide basis,” certainly should be referenced since it states 
an opinion. 

2. The authors have grouped all hospitals other than 
CAMC [Charleston Area Medical Center], Cabell- 
Iluntington and West Virginia University into a single 
category called Community Hospitals. This effectively 
places all hospitals having between one and 1,600 births 
in the same category and therefore introduces an initial 
bias in any statistical analysis. 

For instance [in the following Table], neonatal mortality 
for the Raleigh General Hospital in Beckley for the years 
1978-82 for infants weighing under 2,000 grams was 
179.2/1,000 live births. This figure is equal to, if not 
better than, that given for “perinatal centers.” During 
this period, there was only one maternal transport, and 
that in a patient with severe congenital heart disease and 
a term gestation. 

Table 


Weight 

# 

births 

Fetal 

deaths 

Neonatal 

deaths 

NND rate 

500-999 

63 

26 

16 

432/1,000 

1,000-1,499 

42 

12 

11 

366/1,000 

1,500-1,999 

128 

11 

6 

51.2/1,000 

Total 

233 

49 

33 

179/1,000 

Further anal 

lysis of 

the above 

Table show. 

s that nine 


of the 16 neonatal deaths in the 500-999 range weighed 
under 750 grams. 


3. The use of the 500 to 1,999-gram category prob- 
ably is too all inclusive. These should be separated into 
smaller weight categories. In 1978, 43 per cent of neonatal 
deaths in West Virginia occurred in pregnancies ending 
before the 28th week of gestation; 43.2 per cent weighed 
less than 1,000 grams; and nine per cent, less than 500 
grams. 

4. The decision to undertake maternal transport may 
be influenced in a negative direction by prior knowledge 
of anomaly incompatible with life (54/311 in 1978), by 
weight or gestational- age considerations or anticipated 
labor-delivery intervals. Crude mortality rates include 
these factors as a built-in bias. 

5. The authors should use either neonatal mortality' 
rates or infant mortality rates in a consistent manner. 

Maternal transport is an important consideration; more 
important, however, is the continuing upgrading of the 
larger “community hospitals” to tertiary levels. This is 
occurring and will, I think, predictably lower the number 
of maternal and neonatal transports in the future. The 
“expertise distance” between major medical centers and 
quality “community hospitals” has narrowed appreciably 
in the last decade, and will continue to do so in the 
future. 

Robert P. Pulliam, M. D. Elizabeth Bragg, R. N. 

343 Westwood Drive Candidate. Masters Degree, 

Beckley 25801 Maternity Nursing 

Ohio State University 


Research Methods Defended 


( Editor’s Note: The following is in response to the 

above letter.) 


We welcome this opportunity' to address several im- 
portant points included in Doctor Pulliam’s comments 
about our study which suggests reduced mortality among 
small infants is associated with maternal transfer to 
perinatal centers. 

Many hospitals of all sizes in West Virginia report data 
which show very low mortality among small infants. In 
some cases, the mortality rates are far below those for 
perinatal centers. However, for purposes of analysis it is 
necessary either to examine a large population of infants 
or take a statistical sample of this group. This exercise 
is important since rates calculated from small numbers 
may be due more to chance than to any other identifiable 
feature. In our study we used an entire population of 
infants, and units of analysis were large enough for us to 
note trends and/or associations with confidence. 

Another important principle of investigation is the 
careful justification of categories used in the analysis. 
In our study we chose to compare infant outcomes be- 
tween perinatal centers— hospitals staffed and equipped 
to provide infant intensive care— and all other hospitals. 
Subdivision of the latter group requires justification. 
Should hospitals with equipment for infant intensive care 
be examined separately? Should hospitals with associated 
pediatricians become a separate category? 

Doctor Pulliam suggests that size of a hospital’s birth 
volume may be a good parameter. Our analyses in 
separate studies of infant mortality by size of hospital 
birth volume in West Virginia do not point to any clear 
relationship between these variables. In fact, contrary to 
Doctor Pulliam’s implied assumption that bigger hospitals 
may have better outcomes, our preliminary results sug- 
gest that there may be a negative association between 
size of hospital birth volume and low infant mortality. 

Full discussion of many of these issues may be found 
in a recent article published after the acceptance of our 
manuscript for publication in the Journal; a full review 
of the extensive previous literature on this subject also is 
included: Paneth N et ah: Newborn intensive care and 
neonatal mortality in low-birth-weight infants: A popu- 
lation study. N Engl J Med 1982; 307(3): 149. 


Rosalind C. Parkinson, M.A. 
Department of Community 
Medicine, West Virginia 
University School of Medicine, 
Morgantown 2650C 


Robert C. Nerwood, M.D. 
Department of Obstetrics 
and Gynecology. Marshall 
University School of 
Medicine, Huntington 25701 


106 


The West Virginia Medical Journal 


GENERAL NEWS 


FMG Educational Commission 
Head Keynote Speaker 

An authority in international medicine who 
has held top posts at Johns Hopkins University 
School of Medicine and in Beirut. Lebanon, 
will be the keynote speaker for the State Medical 
Association’s 116th Annual Meeting. 

Dr. Samuel P. Asper, President of the Edu- 
cational Commission for Foreign Medical Gradu- 
ates f ECFMG ) in Philadelphia, will deliver the 
Thomas L. Harris address during opening 
exercises Friday morning, August 26. it was an- 
nounced by the Program Committee. His topic 
will be “Strengths and Weaknesses of the U. S. 
Role in International Medicine. 

The convention will be held August 25-27 at 
the Greenbrier in White Sulphur Springs. 

The ECFMG provides information to FMGs 
about entry into graduate medical education and 
health-care systems, and evaluates FMGs’ qualifi- 
cations. The Commission, a non-profit organiza- 
tion established in 1956, also gathers, maintains, 
and disseminates data regarding FMGs. 

The Annual Meeting will open with a pre- 
convention session of the Association’s Council 
and the first session of the House of Delegates on 
Thursday morning and afternoon. August 25; 
and end with the second and final House session 
and reception for new Association officers on 
Saturday morning and afternoon. 

Dean of American University of Beirut 

Doctor Asper, from 1973 until 1978, was 
Dean of the School of Medicine of the American 
University of Beirut (AUB), one of three over- 
seas schools of medicine affiliated with Johns 
Hopkins, and Chief of Staff of the American 
University Hospital. Under his direction, the 
AUB Medical Center held together during the 
Lebanese civil strife of 1975-76, caring for 
8,500 casualties. For his work in providing treat- 
ment for the American community in Lebanon. 
Doctor Asper received a citation in 1976 from 
the then Secretary of State Henry A. Kissinger. 

Doctor Asper, a native of Texas, has held his 
present ECFMG post since June, 1982, and has 
been Professor of Medicine at Johns Hopkins 


since I960. He was graduated from Baylor L T ni- 
versity, and received his M. D. degree in 1940 
from Johns Hopkins. Following an internship in 
medicine in the Johns Hopkins Hospital, he 
began a fellowship in endocrinology at Harvard. 
This was interrupted by World War II. during 
which he served in the Harvard Medical L^nit 
in Europe for nearly four years. 

Following the war. Doctor Asper resumed his 
fellowship for two years at Harvard, then re- 
turned to Johns Hopkins. In endocrinology, his 
work related to both clinical and research aspects 
of the thyroid gland. As Associate Dean from 
1957 to 1968. he guided postdoctoral activities 
at Johns Hopkins, including the international 
program, and coordinated Johns Hopkins’ affilia- 
tion with the American University of Beirut. 

ACP President 

From 1967 to 1970. Doctor Asper. succes- 
sively, was Vice President. President Elect and 
President of the American College of Physicians, 



Samuel P. Asper, M. D. 


May, 1983, Vol. 79, No. 5 


107 


and, from 1970 to 1973, was Vice President for 
Medical Affairs of the Johns Hopkins Hospital. 

The 9 o'clock opening exercises Friday morn- 
ing will precede the first general scientific ses- 
sion, a “Symposium on Sexually Transmitted 
Diseases' featuring four speakers. As announced 
previously, two of the speakers will be Drs. Lee 
P. Van Voris, Associate Professor of Medicine 
at Marshall University, whose topic will be “Non- 
Luetic, Non-Gonococcal Venereal Diseases,” and 
George J. Pazin, Associate Professor of Medi- 
cine, University of Pittsburgh, “Transmissible 
Diseases of the Gay Patient." 

Other subjects for the Friday morning session 
will be syphillis and gonococcal infections; and 
sexual mores in the 1980s. 

The second and final general scientific session 
will be held Saturday morning and, also as an- 
nounced previously, will be a “Symposium on 
Cardiovascular Diseases.” Individual subjects 
will include new developments in the manage- 
ment of cardiac arrhythmias; an update relative 
to cardiovascular surgery; and the management 
of congestive heart failure. 

In addition to the general sessions, the Annual 
Meeting agenda will include breakfast, luncheon 
and other programs arranged by specialty 
societies and sections, many of which also will 
provide scientific discussions. 

The specialty group meetings will be held in 
large measure on Friday, with a few to be set 
for Saturday morning, preceding the second 
general session and at noon. 

Doctor Adkins to be Installed 

At the final House session on Saturday after- 
noon, Carl R. Adkins, M. D., of Fayetteville will 
he installed as the Association's 1983-84 Presi- 
dent to succeed Harry Shannon, M. D., of 
Parkersburg. 

The Auxiliary to the State Medical Associa- 
tion, with Mrs. Richard S. Kerr of Morgantown 
the current President, as usual will hold its 
meeting in conjunction with that of the Associa- 
tion. 

Members of the 1983 Program Committee 
are David Z. Morgan, M. D., Morgantown, 
Chairman; Doctor Adkins; Jean P. Cavender. 
M. D., Charleston; Michael J. Lewis, M. D., St. 
Marys; Kenneth Seller, M. D., Huntington, and 
Roland J. Weisser, Jr., M. D.. Morgantown. 

Additional information concerning speakers 
and other convention details will be provided 
in upcoming issues of The Journal. 


Continuing Education 
Activities 


Here are the continuing medical education 
activities listed primarily by the West Virginia 
University School of Medicine for part of 
1983, as compiled by Dr. Robert L. Smith, 
Assistant Dean for Continuing Education, and 
J. Zeb Wright, Ph. D., Coordinator, Con- 
tinuing Education, Department of Community 
Medicine. Charleston Division. The schedule is 
presented as a convenience for physicians in plan- 
ning their continuing education program. (Other 
national, state and district medical meetings are 
listed in the Medical Meetings Department of 
The Journal. ) 

The program is tentative and subject to 
change. It should he noted that weekly confer- 
ences also are held on the Morgantown. Charles- 
ton and Wheeling campuses. Further information 
about these may be obtained from: Division of 
Continuing Education, WVU Medical Center, 
3110 MacCorkle Avenue. S. E., Charleston 
25301: Office of Continuing Medical Education, 
WVU Medical Center, Morgantown 26506: or 
Office of Continuing Medical Education, Wheel- 
ing Division. WVU School of Medicine, Ohio 
\ alley Medical Center. 2000 Eoff Street. Wheel- 
ing 26003. 

May 7, Charleston. Outpatient Infectious Dis- 
eases 

May 20-21. Morgantown. Health Officers Con- 
ference 

June 3-4, Morgantown. Anesthesia Update '83 

June 4, Charleston, 10th Annual Wildwater 
Conference — Medical & Surgical Update 

June 11, Morgantown, Interventional Radiology 

Regularly Scheduled Continuing 
Education Outreach Programs from 
WVU Medical Center/ 
Charleston Division 

Buckhannon , St. Joseph’s Hospital, first-floor 
cafeteria, 3rd Thursday, 7-9 P. M. — May 19, 
“Evaluation of Infertility and Frequent Spon- 
taneous Abortions," Bruce L. Berry, M. D. 
June 16, “Sudden Infant Death Syndrome,” 
David Myerberg, M. D. 


108 


The West Virginia Medical Journal 



Cabin Creek , Cabin Creek Medical Center, 
Dawes, 2nd Wednesday, 8-10 A. M. — May 
11, "Hypertension Update,” Steven Grubb, 
M. D. 

Gcissaway, Braxton Co. Memorial Hospital, 1st 
Wednesday, 7-9 P. M. — May 4, “Manage- 
ment of Trauma in the Small Hospital Setting 
and During Transport.” Paul Derboven, M. D. 

June 1, "Common Blood Disorders,” Steven 
Jubelirer, M. D. 

July 6, “The Pharmacology of Hypertension 
Management," Stephen Grubb. M. D. 

Aug. 3, “Diagnosis of Pulmonary Disorders,” 
Dominic Gaziano. M. D. 

Madison, 2nd floor, Lick Creek Social Services 
Bldg., 2nd Tuesday, 7-9 P. M. — May 10. 
“Common Dermatological Problems,” Stephen 
K. Milroy, M. D. 

June 14, “Recently Recognized Sexually — 
Transmitted Diseases,” Thomas W. Mou, 
M. D. 

July 12, “Approach to the Peripheral Vascular 
Patient," Ali F. AbuRahma, M. D. 

Oak Hill, Oak Hill High School (Oyler Exit, N 
19 1 4th Tuesday, 7-9 P. M. — May 24, 
“Pharmacology & Clinical Use of Calcium & 
Beta Blockers," Robert Hoy, Pharm. D. 

W elch, Stevens Clinic Hospital, 3rd Wednesday, 
12 Noon-2 P. M. — May 18. “Gastro- 
intestinal Bleeding,” Warren Point, M. D. 

Whitesville, Raleigh-Boone Medical Center, 4th 
Wednesday, 11 A. M.-l P. M. — May 25. 
“Lower Gastro-Intestinal Disorders.” Warren 
Point, M. D. 

Williamson, Appalachian Power Auditorium, 1st 
Thursday. 6:30-8:30 P. M. — May 5, “Update 
Thyroid Dysfunction," Richard Kleinmann, 
M. D. 


Doctor Point ACP Governor 

Dr. Warren Point of Charleston recently was 
elected a Governor of the American College of 
Physicians. Doctor Point, an internist and 
Chairman of the Department of Medicine, West 
Virginia University Medical Center, Charleston 
Division, will hold his post as Governor of West 
Virginia for four years. 

A native of Charleston, he was graduated 
from WVU, and received his M. D. degree in 
1945 from Harvard Medical School. 


Wildwater Medical-Surgical 
Conference June 3-4 

Colonic and breast cancer will be the subjects 
of the day for the 10th annual Wildwater Con- 
ference: Medical and Surgical Update, on 

Saturday. June 4, in Charleston. 

The meeting site will be the West Virginia 
University Medical Center Education Building, 
witjh the program to begin at 7:30 A. M. and 
end at 3 P. M. Offered on Friday is a wildwater 
trip on New River from Thurmond to Fayette 
Station (15 miles). 

Sponsors are WVU Charleston Division and 
Charleston Area Medical Center. 

The Saturday morning program on “The 
Colonic Cancer Problem” will include five 
speakers, who will join for a panel discussion 
at the conclusion. The speakers and topics will 
be “Chemotherapy-CA of the Colon” — Steven J. 
Jubelirer, M. D., Assistant Professor of Medi- 
cine, WVU Charleston Division; “Colonoscopy” 
— Brittain Mcjunkin, M. D., Clinical Assistant 
Professor of Medicine, WVU Charleston Di- 
vision: “Radiological Diagnosis-CA of the 

Colon” — Clinton A. Briley, M. D., Clinical As- 
sistant Professor of Radiology, WVU Charleston 
Division; 

Boston. Wisconsin Speakers 

“Surgical Treatment of CA of the Colon’ - 
Claude Welch, M. D., Senior Surgeon, Massa- 
chusetts General Hospital, Boston, and Clinical 
Professor of Surgery, Emeritus, Harvard Medical 
School; and “Polyps and Cancer" — Alvin L. 
Watne, M. D., Professor and Chairman, WVU 
Department of Surgery, Morgantown. 

Speakers for the afternoon session, “Breast 
Cancer in 1983,” will be William L. Donegan, 
M. D., Professor of Surgery, University of 
Wisconsin, on “New Approaches to Breast 
Cancer;” Edward Wheatley. M. D., Clinical As- 
sistant Professor of Radiology, WVU Charles- 
ton Division, “Mammography in the Diagnosis 
of CA of the Breast;” and Doctor Jubelirer, 
“Chemotherapy-CA of the Breast.” A panel 
discussion will follow. 

The program is approved for five credit hours 
in Category 1 of the Physician’s Recognition 
Award of the American Medical Association. 

Registration by May 27 is requested for the 
scientific program. The fee, including lunch, 
for physicians is $40 ($45 after May 27). For 
additional information, telephone (304) 347- 
1242. 

The fee for the wildwater trip is $59. For 
additional information or reservations, call ( 304 ) 
348-5511. Reservations are limited. 


May, 1983, Vol. 79, No. 5 


109 


Keep Insanity Defense, Says 
Doctor Bateman’s Group 

The insanity defense in criminal trials should 
not be abandoned, Dr. Mildred M. Bateman and 
other members of a National Mental Health As- 
sociation commission say in a report released 
recently in Washington, D. C. 

Doctor Bateman, Chairman of the Marshall 
University School of Medicine Psychiatry De- 
partment, said the group also opposes adoption 
of the “guilty but mentally ill" verdict. (The 
West Virginia Senate in its recently completed 
session killed a bill which would have created 
this verdict in the state.) 

“One of the myths surrounding the insanity 
defense is that it causes major problems for law 
enforcement and the criminal justice system. ' 
Doctor Bateman said. “Actually, it’s successfully 
used infrequently enough that it causes few 
practical problems, but it does have a very 
important moral role. We found that in a society 


Review A Book 


The following books have been received by the 
Headquarters Office of the State Medical Associa- 
tion. Medical readers interested in reviewing any 
of these volumes should address their requests to 
Editor, The West Virginia Medical Journal , Post 
Office Bo\ 1031, Charleston 25324. We shall be 
happy to send the books to you, and you may 
keep them for your personal libraries after sub- 
mitting to The Journal a review for publication. 

Basic and Clinical Pharmacology , by Bertram 
G. Katzung, M. D., Ph.D. 815 pages. Price 
$23.50. Lange Medical Publications, Los Altos. 
California 94022. 1982. 

Living With Herpes, by Deborah P. Langston. 
M. D. 198 pages. Price $7.95. Doubleday & 
Company. Inc., 245 Park Avenue, New York. 
New York 10167. 1983. 

Current Medical Diagnosis and Treatment, 
1 983, edited by Marcus A. Krupp, M. D.; and 
Milton J. Chatton. M. D. 1130 pages. Price $24. 
Lange Medical Publications, Los Altos, Cali- 
fornia 94022. 1983. 

General Ophthalmology, 10th Edition, by 
Daniel Vaughan. M. D.; and Taylor Asbury, 
M. D. 40 7 pages. Price $17. Lange Medical 
Publications, Los Altos, California 94022. 
1983. 


that has as its core a concern for the individual, 
the plea is not only an appropriate part of the 
criminal code, but a necessary one as well.” 

She said that the “not guilty by reason of 
insanity plea is used much less often than many 
people believe. “Testimony before our commis- 
sion indicated that of the 32.000 adult defend- 
ants represented by the New Jersey public de- 
fender last year, 52 entered insanity pleas — 
and only 15 were successful,” she said. “In 
Virginia, fewer than one per cent of the felony 
cases involve the insanity defense.” 

Disposition of Those Acquitted 

The group also recommended that legislatures 
adopt laws concerning the disposition of persons 
acquitted under the insanity defense. 

“We think that a lot of the public’s fear and 
concern about the insanity defense is not so 
much that a person can be acquitted because 
he’s proven mentally ill, but what happens after- 
ward." Doctor Bateman said. “Is he returned 
to society as a free agent, or are there appropri- 
ate custody and treatment programs available? 

“The responsibility of the court does not end 
with the Ending of not guilty by reason of in- 
sanity." she said. “We recommend that the 
states develop — and adequately fund 
systems for providing treatment.” 

She added that such programs reduce repeat 
crimes. “Testimony we heard indicated that 76 
per cent of patients released from Maryland’s 
treatment and conditional release program were 
not re-arrested in the four-year study period,” 
she said. 

The nine-member commission, led by former 
U. S. Senator Birch Bayh. was formed to study 
issues raised following the trial of presidential 
assailant John Hinckley. 


Group Elects MU Doctor 

Dr. David K. Heydinger of the Marshall Uni- 
versity School of Medicine was elected President- 
Elect of the National Rural Primary Care As- 
sociation at its recent annual meeting in Kansas 
City. 

He currently serves on the group’s board. 

Doctor Heydinger, who joined the faculty in 
1978. is Associate Dean for Academic Affairs 
and Chairman of the Department of Family and 
Community Health. 


110 


The West Virginia Medical Journal 


Residency Locations Announced 
For Marshall Graduates 

Seventeen members of the Marshall University 
School of Medicine’s 1983 graduating class of 
36 students will remain in West Virginia for 
their residencies, Dean Robert W. Coon, M. D., 
has announced. 

Nine of the 17 will remain in Huntington, and 
the others will go to Wheeling, Morgantown. 
Clarksburg and Charleston, he said. 

Remaining in Huntington are Frederick D. 
Adams and Richard M. Hatfield, both of Logan: 
Denise E. Clay Allen of Gilbert: Karen N. 
Dansby of Ashland. Kentucky; Durwood F. 
Gandee of Weirton; William D. Given of Strange 
Creek: John L. Hahn of Wardensville; Darrell 
W. Jordan of Ona, and Lou Gene Kingery of 
Ken ova. 

Other graduating seniors remaining in West 
Virginia and their residency locations are: 
David A. Brosius of Sutton and Kelly M. 
Pitsenbarger of Franklin, United Hospital 
Center, Clarksburg; Samuel R. Davis of 
Marlinton and Wayne E. Groux of Wheeling. 
Ohio Valley General, Wheeling: 

Ronald DeAndrade, Jr., of Buckhannon. West 
\ irginia University Hospital: Daniel B. Prudich 
and Reginald J. McClung, both of Charleston, 
and Mark K. Stephens of Madison, Charleston 
Area Medical Center. 

Other students and their residency locations 
are: Gerald G. Blackwell of Gauley Bridge. 

Ohio State University Hospitals; Leo R. Boggs, 
Jr., of Danville, Hershey I Pennsylvania I Medi- 
cal Center; Craig L. Bookout of Philippi, Self 
Memorial Hospital. South Carolina: Mary B. 
Butcher of Glenville, Riverside Methodist Hos- 
pital. Ohio: James W. Endicott of Kermit, North 
Carolina Baptist; 

Albert J. Exner of Huntington, University of 
Maryland; Bijan J. Goodarzi of Elkins, Akron 
(Ohio I City Hospital: Garrie J. Haas of 

Charleston, Ohio State University Hospital: 
James D. Hoffman of Huntington, University 
Health Center Hospitals, Pittsburgh; Harry J. 
Magee of Charleston. University of California. 
Los Angeles; Larry D. Mann of Princeton, Ohio 
State University Hospitals; 

Bradley R. Martin of Princeton, Akron City 
Hospital; William E. Muth of Morgantown, Uni- 
versity Hospitals, Madison, Wisconsin; Daniel 
B. Ray of Ironton, Ohio. Aultman Timken Hos- 
pitals, Ohio; Hobart K. Richey of Wellsburg, 
University of Southern Florida-affiliated hos- 
pitals; 


William S. Sheils, Jr., of Huntington. Ohio 
State l niversity Hospitals; Carol M. Spencer 
of Huntington. Maine Medical Center; Sandra 
L. Tabor of Switzer, Ohio State University 
Hospitals, and Samuel D. Wellman of Kenova, 
University of Louisville-affiliated hospitals. 


Majority Of WVU Graduates 
Choose Primary Care 

Primary care specialties are the residency 
choice of more than half the West Virginia Uni- 
versity School of Medicine class of 1983. 

Of the 80 seniors who will receive their M. D. 
degrees on May 15. 46. or 57.5 per cent, will 
take all or part of their postgraduate training 
in either internal medicine, family practice or 
pediatrics. Internal medicine is the choice of 22. 
14 opted for family practice, and six chose 
pediatrics. 

Another three will combine pediatrics and 
medicine residencies, and one will combine 
medicine with psychiatry. 

Exactly half of this year s class will remain 
in West Virginia, including 21 at WVU, 16 at 
the Charleston Area Medical Center (CAMC), 
one at Ohio Valley Medical Center in Wheeling, 
and two in Wheeling Hospital's Family Practice 
Program. 

Primary care areas also are the choice of 
more than 67 per cent of those staying in the 
state. Thirteen will enter family practice pro- 
grams, 12 chose internal medicine, and two will 
enter pediatric residencies. 

Other residency choices among seniors are: 
surgery, 12; emergency medicine, 5; ophthal- 
mology and radiology, 4 each; psychiatry, 3; 
anesthesia, 2, and obstetrics /gynecology, ortho- 
pedics and pathology, one each. 

One will enter a flexible residency program 
and choose a specialty after the first year. 

Class of ’83 

Members of the class of 1983, their home- 
towns and destinations are: 

Arif A. Alidina, Lewdsburg, LTniversity of 
Pittsburgh Health Center Hospitals; Robert D. 
Allara, Iaeger, WVU Department of Ophthal- 
mology; Michael T. Angotti, Clarksburg, Medi- 
cal College of Virginia. Richmond: Harold G. 
Ashcraft, Mannington, WVU Department of 


May, 1983, Vol. 79, No. 5 


111 


Medicine: William C. Bird. Matoaka. WVU De- 
partment of Pathology; Wayne R. Brearly, 
Morgantown, Mercy Hospital, Pittsburgh; John 
A. Burdette, St. Albans, CAMC: Kim B. Carey. 
Weirton, WVU Department of Family Practice; 
Janet E. Cogar. Flatwoods, University of Ken- 
tucky Hospital, Lexington; Brad R. Cohen, 
Charleston, CAMC; 

Steven W. Collins, Glenville, North Carolina 
Baptist Hospitals, Winston-Salem; Anne C. 
Cutlip, Webster Springs, WVU Department of 
Family Practice; William B. Dennison, Hunting- 
ton, University of Kentucky Hospital, Lexington; 
Mark T. Domenick, Morgantown, WVU Depart- 
ment of Family Practice; Joseph D. Dye, Hunts- 
ville, Alabama, Andrews Air Force Base Hos- 
pital; Karen M. Fanucci, Morgantown, Mount 
Auburn (Massachusetts) Hospital: Patrick R. 
Felice, Morgantown. Saint Francis Hospital. 
Connecticut; Linda S. Gray, Wheeling, Uni- 
versity of Massachusetts Hospitals; Mark K. 
Greathouse, New Manchester. Mercy Hospital. 
Pittsburgh; Karen M. Gross. Martinsburg, WVU 
Department of Family Practice; 

Lynn H. Harris, Charleston. WVU Depart- 
ment of Radiology: Jeffrey P. Hogg, Berkley. 
University of Pittsburgh Health Center Hos- 
pitals; Gavin N. Hogue, Scott Depot, CAMC: 
Thomas L. Hurt, Morgantown, LTniversity of 
California at San Diego; Richard J. Jackson. 
Martinsburg, WVU Department of Surgery: 
Jocelyn L. James, Morgantown. LIniversity of 
Texas Health Science Center. San Antonio: 
David T. Kirk, Scott Depot. Hunterdon Medical 
Center, Flemington, New Jersey; Vincent P. 
Kolanko, Weirton, WVU Departments of Medi- 
cine and Pediatrics; 

Susan L. Koletar, Pittsburgh, CAMC; Robert 
W. Koss, Fairmont, WVU Department of Anes- 
thesia; John S. Koval, Weirton, CAMC; Jane 
A. Ku rucz, Morgantown, Ochsner Foundation 
Hospital, New Orleans; Lester Labus, Barbours- 
ville, and John A. Lane, Charleston, CAMC; 
Robert A. Leadbetter, Morgantown, University 
of Virginia Hospital, Charlottesville; Carolyn L. 
I.ooney. Morgantown, Quillen-Disluin College of 
Medicine, Johnson City, Tennessee; John A. 
Mardones, Clarksburg, Rush-Presbyterian-St. 
Luke s Medical Center, Chicago; David C. 
Martin, Charleston, St. Louis University Hos- 
pitals; Scott A. McNamara, Wheeling, George- 
town University Hospital, Washington, D. C.: 
Loren M. Meyer, Lutheran General Hospital, 
Chicago; Aileen H. Miller, Chapel Hill, North 
Carolina, Moses H. Cone Memorial Hospital. 
( Continued on page xxiii ) 


New Patient Record Law 
Effective In June 

Here is the 1983 state legislative enactment, 
proposed by the State Medical Association, 
setting up provisions under which patients may 
obtain copies of summaries of their records from 
health care providers, including physicians. The 
new act will be effective June 10. 

“ARTICLE 29 I in Chapter 16 of the Code). 

HEALTH CARE RECORDS. 

Ҥ16-29-1. Copies of health care records 
to be furnished to patients. 

Any licensed, certified or registered health 
care provider so licensed, certified or registered 
under the laws of this state shall, upon the 
written request of a patient, his authorized agent 
or authorized representative within a reasonable 
time, furnish a copy or summary of the patient’s 
record to the patient, his authorized agent or 
authorized representative subject to the follow- 
ing exceptions: 

( a ) In the case of a patient receiving treat- 
ment for psychiatric or psychological problems, 
a summary of the record shall be made available 
to the patient, his authorized agent or authorized 
representative following termination of the treat- 
ment program. 

( b ) Nothing in this article shall be construed 
to require a health care provider responsible for 
diagnosis, treatment or administering health care 
services in the case of minors for birth control, 
prenatal care, drug rehabilitation or related ser- 
vices, or venereal disease according to any pro- 
vision of the code, to release patient records of 
such diagnosis, treatment or provision of health 
care as aforesaid to a parent or guardian, without 
prior written consent therefore from the patient, 
nor shall anything in this article be construed to 
apply to persons regulated under the provisions 
of chapter eighteen ( education ) of this code or 
the rules and regulations established thereunder. 

I c I The furnishing of a copy or summary of 
the reports of x-ray examinations, electrocardio- 
grams and other diagnostic procedures shall be 
deemed to comply with the provisions of this 
article. 

(dl For purposes of this article, “patient 
record' does not include a provider's office 
notes. 

( e ) The provisions of this article may be 
enforced by a patient, authorized agent or 
authorized representative, and any health care 
provider found to be in violation of this article 


112 


The West Virginia Medical Journal 


shall pay any attorney fees and costs, including 
court costs incurred in the course of such en- 
forcement. 

Ҥ16-29-2. Reasonable expenses to be 
reimbursed. 

The provider shall he reimbursed by the 
person requesting in writing a copy of such 
records at the time of delivery for all reasonable 
expenses incurred in complying with this article.” 


Council Action Embraces 
Variety of Subjects 

Concern regarding the potential impact of a 
new state law setting up a hospital rate review 
and rate setting mechanism was expressed by the 
State Medical Association’s Executive Committee 
and Council during April 9-10 meetings in 
Charleston. 

Major provisions of the 1983 enactment were 
outlined in a Journal story in April, and Harry 
Shannon, M. D., the Association’s President, has 
devoted his monthly page to that issue this 
month (seepage 104). 

Council has instructed the Association staff 
and legal counsel to monitor closely implementa- 
tion of the new statute, to the extent of studying 
the advisability of entering into any litigation 
which might develop to test the law’s various 
components. 

In other action on April 10, the Council: 

— Charged the Executive Committee and Com- 
mittee on Professional Liability to meet with 
representatives of CNA and McDonough Caper- 
ton Shepherd to fashion a more comprehensive 
loss control effort in line with the Association- 
endorsed professional liability insurance pro- 
gram. 

Health Director Reports 

— Heard State Health Director L. Clark 
Hansbarger, M. D., report that each county 
health department soon will have in hand ex- 
tensive new statistical and other data that will 
be used in planning future activity and working 
with county commissions on budgets. 

— Received a progress report on continued 
planning toward a state headquarters building 
in information provided by John Markey, M. D., 
in his role as President of West Virginia State 
Medical Association Properties, Inc. 

— Reviewed other 1983 legislative activity, 
including enactment of a new statute relative to 


patient records which is printed in its entirety 
on page 112 of this issue of The Journal. 

— Elected Carl J. Roncaglione, M. D.. to the 
West Virginia Medical Political Action Com- 
mittee ( WESPAC ) Board as the nucleus member 
from the Third Congressional District to replace 
Joseph T. Skaggs. M. D., who resigned. 

Bylaws Amendments 

— Approved for introduction in the Associa- 
tion’s House of Delegates in August bylaws 
amendments to make a Committee on Audit and 
Budget a standing committee. 

— Authorized introduction in the American 
Medical Association House of Delegates in June, 
in Chicago, resolutions to add state medical as- 
sociation society presidents as members of the 
House; and calling on the AMA to withdraw all 
support from the Joint Commission on Accredita- 
tion of Hospitals in view of proposed JCAH 
standards revisions eliminating the term “medi- 
cal staff" in lieu of an “organized staff. A draft 
of the revisions also would, among other things, 
eliminate references to physician responsibility 
for the general condition of hospitalized patients; 
and eliminate references to physician supervision 
of treatment provided by limited licensed 
practitioners. 

—Voted to ask Thomas G. Potterfield. M. D., 
of Lewisburg to represent the Medical Associa- 
tion on a School Health Advisory Council to 
work with state education and health depart- 
ments toward a comprehensive school health pro- 
gram in West Virginia. 

Honorary Memberships 

— Elected to honorary membership, in the 
wake of appropriate local society action, the 
following: Drs. Eugene E. Hutton, Jr., Elkins; 
Albert C. Esposito, Huntington; Edward Jackson, 
St. Albans; Marion F. Jarrett, Charleston; 
George R. Mullins, Logan; Charles S. Flynn, 
Bluefield; Lawrence J. Pace, Princeton; Robert 
T. Bandi and James C. Hazlett, both of 
Wheeling; Robert M. Biddle, Little Hocking, 
Ohio, and Jack J. Stark, Belpre, Ohio (both 
Parkersburg Academy members ) ; and Grover 
C. Hedrick, Jr., Paul E. Vaughan, Everett B. 
Wray and John W. Whitlock, all of Beckley. 

— Elected to retired membership Drs. J. 
Dennis Kugel, Charleston; James L. Deadwyler, 
Fairmont: and Andrew K. Butler, Herman Rubin, 
William J. Steger and Robert 0. Strauch, all of 
Wheeling. 


May, 1983, Vol. 79, No. 5 


113 


Handicapped Newborn Rules 
Challenged By AMA 

The American Medical Association will file 
an amicus brief in a suit challenging new regu- 
lations in the treatment of severely handicapped 
newborns. The friend-of-the-court brief will be 
in support of a suit hied in March by the 
American Academy of Pediatrics and the Na- 
tional Association of Children's Hospitals. 

The suit seeks to block enforcement of rules 
requiring all hospital maternity wards, obstetri- 
cal wards, and nurseries to post notices warning 
that failure to feed and care for handicapped 
infants is prohibited by law. 

The notices encourage anyone who thinks an 
infant is being denied food or “customary medi- 
cal care” to call a hot line at the U. S. Depart- 
ment of Health and Human Services, or to 
telephone the state’s child protection agency. 

“The purpose of a rule like this goes beyond 
the decision between physicians and families 
concerning a handicapped infant, ' said AMA 
Executive Vice President James H. Sammons, 
M. D. “Once a government agency has inter- 
jected itself into the practice of one medical 
specialty, that kind of interference could be ex- 
panded to other specialties. Then each of us — 
physicians and patients — would have our de- 
cisions subjected to review by strangers making 
arbitrary and perhaps capricious judgments 
about our own life and death events, " he said. 

The AMA will object to the unusually brief 
public comment period before the rules went into 
effect. The AMA also is opposed to a provision 
that allows HHS investigators to have 24-hour 
access to facilities if necessary to protect the life 
or health of a handicapped infant. 

The HHS rule was developed in response to 
the death last year of a six-day-old boy afflicted 
with Down’s syndrome. “Baby Doe died in 
Bloomington, Indiana, after bis parents re- 
quested that food and medical treatment be with- 
held. 


Doctor Traubert Appointed 

Dr. John W. Traubert of Morgantown recently 
was appointed to the Mead Johnson Awards 
Committee of the American Academy of Family 
Physicians. The committee was established to 
administer an annual grant financing a year of 
graduate training in an approved family practice 
residency. Doctor Traubert is Professor and 
Chairman, Department of Family Practice, West 
Virginia University School of Medicine. 


Medical Meetings 


May 2-6 — Am. Psychiatric Assoc., New York City. 

May 4-7 — WV Chapter, Am. College of Surgeons, 
White Sulphur Springs. 

May 6-8 — Southern Medical Assoc. Regional Post- 
graduate Conference, Lexington, KY. 

May 8-12 — Am. College of Obstetricians & Gyne- 
cologists, Atlanta. 

May 13-14— Topics in Cardiovascular Diseases (Am. 
Heart Assoc.), Baltimore. 

May 19-20 — National Conference, Breast Cancer 
(Am. Cancer Society), Boston. 

May 20-22 — Am. Counseling Assoc., Morgantown. 

May 26-28 — Am. Assoc, of Genitourinary Surgeons, 
White Sulphur Springs. 

June 5-9 — Am. Society of Colon & Rectal Surgeons. 
Boston. 

June 7-10 — Society of Nuclear Medicine, St. Louis. 

June 17-18 — Society for Vascular Surgery, San 
Francisco. 

June 19-23 — Annual Meeting of AMA House, Chi- 
cago. 

June 22-25 — Am. College of Surgeons, Eastsound, 
WA. 

June 23-26 — Am. Medical Women’s Assoc., Minne- 
apolis. 

Aug. 25-27 — 116th Annual Meeting, W. Va. State 
Medical Assn., White Sulphur Springs. 

Sept. 29-Oct. 2 — Am. Society of Internal Medicine, 
San Francisco. 

Oct. 16-21 — Am. College of Surgeons, Atlanta. 

Oct. 22-27— Am. Academy of Pediatrics, San Fran- 
cisco. 

Oct. 23-27 — Am. College of Chest Physicians, 
Chicago. 

Oct. 23-29 — Am. College of Gastroenterology, Los 
Angeles. 

Nov. 6-9 — Scientific Assembly, Southern Medical 
Assoc., Baltimore. 

Nov. 30-Dec. 1 — Am. College of Chemosurgery, 
Chicago. 


114 


The West Virginia Medical Journal 




By now, car shoppers have resigned themselves to paying upwards of 
$11, 000 for even an ordinary car. 

This is unfortunate. Also unnecessary. Because for about the same money, 
they could have an extraordinary car: the Saab 900. 

The Saab 900 has everything the name would suggest and the price 
wouldn’t, like jetronic fuel injection, a zero pollen air filter, 4-wheel disc brakes, 
rack-and-pinion steering. As for front-wheel drive, we consider that so basic, we 
don’t even bother to put it on the sticker. 

Which brings up something else: While you could pay extra to get some of 
Saab’s features on another car, you’d still have another car. 

Or maybe Road & Track said it better. “Price is one of the things that makes 
the 900 so attractive. The other is that it’s a Saab. ” 

The most intelligent car ever built. 



Harvey Shreve, Inc. 

ROUTE 60, WEST ST. ALBANS 722-4900 


WVU Medical Center 
—News— 




Compiled from material furnished by the Medical Center 
News Service, Morgantown, W. Va. 


ENT Laboratory Arm Of CDC 
In AIDS Cause Quest 

Acquired immune deficiency syndrome 
(AIDS) is a modern medical mystery. 

Scientists know that its greatest incidence is 
among male homosexuals, Haitians and abusers 
of intravenously injected drugs. The syndrome 
also has affected some hemophiliacs, leading 
researchers to believe its transmission may be 
linked to blood products. 

AIDS directly results from an imbalance in 
subsets of certain white blood cells which brings 
about a suppression of the immune response. 

What changes this delicate balance? Is it 
some bacterium, virus or combination of 
pathogens? Or are many recurrent infections 
from, or re-exposures to, some ever present, 
disease-producing agent the answer? 

As a regional laboratory for the Centers for 
Disease Control ( CDC ) in Atlanta, WVU’s ENT 
Diagnostic Laboratory is playing a part in 
adding to the body of knowledge concerning this 
phenomenon. 

Virology and Immunology 

The laboratory specializes in virology and 
immunology. Its Director, James E. McClung, 
M.S., took much of his graduate study at the 
CDC with special emphasis on the Epstein-Barr 
virus, one of the herpes family. 

“CDC is interested in looking at the individual 
with a slightly lowered cell-mediated immune 
response who may be borderline for AIDS,” 
McClung said. “In that way they hope to come 
up with an etiological agent.” 

“Probably the causative agent has come and 
gone in the active AIDS cases who have 
opportunistic infections or Kaposi’s sarcoma.” 

Kaposi’s sarcoma, a rare type of skin cancer, 
is found in 28 per cent of AIDS patients. Nearly 
half of them fall victim to pneumocystis carinii 
pneumonia, a protozoa infection. 



But these diseases are believed to be the 
results of impaired immunity, not its cause. 

The instigator may be an ultravirus or a new 
virus, McClung said. 

“The current theory, however, is that AIDS 
individuals have repeated bouts of infection with 
cytomegalovirus, herpes simplex or possibly 
Epstein-Barr, all members of the herpes family,” 
he explained. 

CMV Prime Suspect 

“C.MV is probably the prime suspect right 
now. Most individuals have very minor 
symptoms with it. They get over it and have 
no further problems. CMV causes a problem 
with organ transplant patients and cancer 
patients who are immunosuppressed. 

“When the herpes viruses are active, the infec- 
tion itself causes a suppression of the immune 
response. It may be that AIDS victims have so 
many recurrent infections or re-exposure to the 
viruses that their immune systems just finally 
break down.” 

Hepatitis B, which also is found frequently 
among homosexuals and drug users, and known 
to be transmitted in blood products, also is 
suspected as a contributing factor. 

McClung said the diagnosis for AIDS was 
made by the determination of the ratio of helper 
T-cells to suppressor T-cells in a blood sample. 
These white blood cells are involved in the 
immune response — the helper cells fighting off 
infection by aiding in the production of anti- 
bodies, and the suppressor cells stopping the 
response. 

“In AIDS, the problem is a lower number of 
helper cells but an increased number of suppres- 
sor cells,” he said. 


Foundation Appointment 

Jack E. Riggs, M. D.. Assistant Professor of 
Neurology, has been appointed to the medical 
advisory hoard of the national Myesthenia Gravis 
Foundation. Doctor Riggs is a medical graduate 
of the University of Rochester, and joined the 
WVU faculty in 1981. 


xvi 


The West Virginia Medical Journal 


Be a Physician 
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Huntington, WV 304-529-5396 
Roanoke, VA 703-982-4612 
Richmond, VA 804-771-2127 

/iWllIEoIirST^ 


A great way of life. 


Third-Party News, Views 
and Program Concerns 



Prospective Payment Approved, 
‘Heavy Impact' Expected 

Attached to the Social Security Act of 1983 
recently approved by Congress and signed by 
President Reagan are measures that will have 
heavy impact on the nation’s health care system, 
the American Medical Association has com- 
mented. The bill contains provisions to hold 
down the cost of Medicare payments to hospitals 
through a prospective payment plan based on 
diagnosis-related groups (DRGs). Hospitals will 
be paid on the basis of 467 DRGs regardless of 
the costs actually incurred in treating patients. 

Under the bill approved by Congress: 

— DRG payments will be phased in over three 
years, beginning with the hospital’s first cost re- 
porting period after October 1, 1983. In the first 
year, 25 per cent of the payment will be based 
on DRG rates, and 75 per cent on the hospital’s 
cost base. The percentage of the payment based 
on DRGs gradually will increase until it reaches 
100 per cent in the fourth year. 

— In the first year, the DRG portion of the 
payment will be a regional rate. A rural and an 
urban rate will be calculated for each of nine 
regions. In the second and third years, the DRG 
portion will be a blend of national and regional 
rates and, by the fourth year, the 18 regional 
rates will give way to two national rates — one 
urban, one rural. 

1984-85 Rates 

-Rates in 1984 and 1985 will be adjusted by 
the market-basket index of hospital costs plus 
one per cent, but they would be reduced to the 
extent this resulted in payments exceeding those 
that would have applied under the Tax Equity 
and Fiscal Responsibility Act targets. 

—Beginning in 1986, the increase factor will 
be determined by the Secretary of Health and 
Human Services and reviewed by a 15-member 
commission appointed by the Office of Tech- 
nology Assessment. The commission is to include 
representatives of a wide range of groups, in- 

xviii 


eluding new technology and treatments, and is to 
recommend changes in the recalibration of the 
DRG classifications. 

Direct medical education expense will con- 
tinue to be paid on a cost basis, and the current 
Section 223 adjustment for indirect medical edu- 
cation expenses will be doubled in the DRG 
system. 

Capital Costs 

— Capital costs incurred before the system 
took effect will continue to be reimbursed on a 
reasonable cost basis until October 1. 1986. New 
capital costs may or may not be paid on a rea- 
sonable cost basis. States will be required to 
have Section 1122 review systems, and Medicare 
reimbursement for new capital costs will be con- 
ditioned on 1122 approval. The maximum thres- 
hold the state may use for requiring an 1122 
review is increased from $100,000 to $600,000. 

— Return on equity for proprietary hospitals 
will be reduced. 

— Certain types of institutions will be exempt 
from the DRG system. 

— From now until October 1, 1983, hospitals 
are required to contract with a Professional Re- 
view Organization I PRO I to monitor utilization 
if there is a PRO in the area. After October 1. 
the hospital is required to contract with a PRO. 
and cannot be paid by Medicare if a PRO review 
is not performed. Intermediaries will be allowed 
to participate in the PRO program by October 
1, 1984, at the latest. 

Physician Charges Eyed 

— State payment systems covering all payors 
will be encouraged through waivers if the state 
system will cost Medicare no more than the 
federal DRG system. 

-HHS is to report in 1985 on the ‘'advisabil- 
ity and feasibility” of applying DRGs to physi- 
cian charges for hospital services, and is to 
recommend legislation to apply DRGs to physi- 
cians. 

The West Virginia Medical Journal 



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Obit uaries 


JAMES H. THORNBURY, M. D. 

Dr. James H. Thornbury of Belle ( Kanawha 
County ) died on March 19 in a Charleston 
hospital. He was 74. 

Doctor Thornbury was a retired physician for 
the DuPont plant in Belle. He was Belle’s first 
mayor. 

Born in Genoa (Wayne County), he formerly 
practiced in Man (Logan County | before going 
to Belle 43 years ago. He was a former physician 
for the University of Charleston. 

Doctor Thornbury was graduated from West 
Virginia University, and received his M. D. de- 
gree in 1936 from Jefferson Medical College. He 
interned at Newark (New Jersey) Memorial 
Hospital. 

Doctor Thornbury was a member of the 
Kanawha Medical Society, West Virginia State 
Medical Association and American Medical 
Association. 

Survivors include the widow; three sons, 
James Thornbury of Webster. New York; Robert 
Thornbury of St. Petersburg, Florida; and David 
Thornbury of Lexington, Kentucky; a brother, 
Lawrence Thornbury of Asbury I Greenbrier 


County), and three sisters, Mrs. Frances Prochilo 
of Massapequa. New York; Mrs. Nancy Cairoof 
of Hampstead, New Hampshire, and Mrs. 
Romaine Melara of Lewisburg. 

# # # 

THOMAS V. SHIELS, M. D. 

Dr. Thomas V. Shiels of South Charleston 
died on March 21 at his home there. He was 77. 

Doctor Shiels, an internist, was a retired 
physician for the Lfnion Carbide Corporation in 
South Charleston. 

Born in Craven. Saskatchewan. Canada, he 
received both his undergraduate an d M. D. 
(1939) degrees from the University of Illinois. 
He interned at Swedish Covenant Hospital, and 
took his residency at the Louisville Veterans 
Administration Medical Center. 

Doctor Shiels also had practiced for short 
periods in Fayetteville. North Carolina, and 
W illiamson. 

Survivors include the widow; a stepson, 
Paul Epperly of Ellenboro: a sister. Mrs. 

Marjorie Thibodeau of \ ictoria, British Colum- 
bia. Canada: and two brothers, Warren Shiels 
of Standard. California, and Leonard Shiels of 
Craven, Saskatchewan. 

He was an honorary member of the Kanawha 
Medical Society. West Virginia State Medical 
Association and American Medical Association. 


HIGHLAND HOSPITAL 

56TH & NOYES AVE., S.E. 
CHARLESTON, W. VA. 25304 
925-4756 


MEDICAL STAFF 


ADULT PSYCHIATRY 

Miroslav Kovacevich, M. D. 925-0693 

Charles C. Weise, M. D. 925-2159 

Thomas S. Knapp, M. D. 925-3554 

Pablo M. Pauig, M. D. 343-8843 

Ralph S. Smith, M. D. 925-0349 

Lee L. Neilan, M. D. 925-0349 

Edmund C. Settle, Jr., M. D. 925-6914 
Gina Puzzuoli, M. D. 925-6914 

John P. MacCallum, M. D. 925-6966 


CHILD PSYCHIATRY 

Henrietta L. Marquis, M. D. 
Pablo M. Pauig, M. D. 

Ralph S. Smith, M. D. 

John P. MacCallum, M. D. 


925-3160 

343-8843 

925-0349 

925-6966 


Psychiatric treatment for the emotionally 
disturbed children ages 5 to 13 now avail- 
able in new children's pavilion. Separation 
maintained from adult psychiatric care 
unit. Each program offers: 

• Crisis Intervention 

• Group Therapy 

• Psychotherapy 

• Activities & Recreational Therapies 

• Skilled Attention to Family, Marital, and 
Individual Emotional Problems 

• Special Care for the Acutely Disturbed 
Patient 

• Staffed by Qualified Psychiatrists and 
Medical Consultants 

« Schooling Provided on Children’s Pa- 
vilion 

• Serving the Community for Over 25 
Years 


xx 


The West Virginia Medical Journal 


County Societies 


FAYETTE 

The Fayette County Medical Society met on 
March 2 at Montgomery General Hospital. 

The guest speaker was Dr. Kenneth M. 
Harman of Charleston, whose topic was “Total 
Parenteral Nutrition.” — S. S. Maducdoc, Jr., 
M. D., Secretary /Treasurer. 

# # 

JEFFERSON 

Dr. Rebecca Garrett of Hagerstown. Maryland, 
was the guest speaker for the meeting of the 
Jefferson County Medical Society on March 2. 
Her topic was “Arthritis.” 

New officers were elected. — William S. Miller. 
M. D., Secretary /Treasurer. 

* * # 

McDowell 

The McDowell County Medical Society met 
on March 9 in Welch at the Stevens Clinic Hos- 
pital. 

The guest speaker was Dr. Robert Lapin. 
Clinical Assistant Professor of Medicine, In- 
fectious Diseases. Albert Einstein Medical 
College, New York City. His subject was 
“Update on the Management of Medical and 
Surgical Infections.” — Muthusami Kuppusami. 
M. D., Acting Secretary. 


Plant Medical Director 

Physician is required to take charge of 
established program in occupational medi- 
cine. Previous experience or training in 
occupational medicine is preferred. Com- 
petitive starting salary and exceptional 
benefits are available to a physician inter- 
ested in residing in the Parkersburg, WV/ 
Marietta, OH area. Send CV to Box PAC, 
c/o The West Virginia Medical Journal, 
P. O. Box 1031, Charleston, WV 25324. 


EQUIPMENT WANTED 

WANTED TO BUY— Second hand office 
and exam room equipment. Also, instru- 
ments appropriate for Family Practice. 
Send responses to Joseph I. Golden, M. D., 
P. O. Box 1645, Beckley, WV 25801. 


WVU GRADS — Continued from page 112 

Greensboro. North Carolina: Frederick E. Moore, 
Charleston. Aultman Hospital. Canton. Ohio: 

Larry W. Moreland, Mount Storm, WVU De- 
partment of Medicine; Michael S. Solomon. 
Parkersburg, CAMC; Alan L. Myers, Philippi. 
W\ U Department of Behavioral Medicine and 
Psychiatry: Patton V. Nickell. Buckhannon, 
WVU Departments of Medicine and Behavioral 
Medicine and Psychiatry: Ross S. Oliver. 

V heeling. CAMC: Lawrence N. Payne, Parkers- 
burg, Akron (Ohio) City Hospital; Debra G. 
Perina, Harpers Ferry, Richland Memorial Hos- 
pital. Columbia. South Carolina; Stuart W. Point, 
Charleston. CAMC; Stephen R. Powell, Scott 
Depot, WVU Department of Ophthalmology; 
Lee A. Pyles. Fairmont, University of Minnesota 
Hospitals; Janis E. Reed. Morgantown, St. 
Francis General Hospital. Pittsburgh; Gary J. 
Renaldo, Fairmont. Medical College of Virginia; 
David M. Ritchie. Ravenswood, CAMC: Charles 
L. Rolfe. Morgantown, Ohio Valley Medical 
Center, Wheeling: William D. Rose, Geisinger 
Medical Center. Charlton Heights. Pennsylvania: 

David B. Rymer. Parkersburg, WVU Depart- 
ment of Anesthesia; Ralph A. Sellers, Fairmont. 
LIniversity of Mississippi Hospital: Henry L. 
Setliff. Shady Spring. Lbiiversity of South 
Florida Medical Center, Tampa: Robert N. 

Shobe, Burlington. Allegheny General Hospital. 
Pittsburgh; Sydney G. Short. Morgantown. 
North Carolina Baptist Hospital: Cynthia C. 
Sims. Colbers; William R. Sims. Huntington, 
and Daniel L. Smith, Sissonville, CAMC: 
Gregory D. Snodgrass, Gauley Bridge, and 
Natalie C. Snodgrass, Wheeling. Ohio State Uni- 
versity Hospitals; Thomas J. Soltis. Huntington. 
WVU Department of Medicine; Jack R. Steel, 
Morgantown, WVU Department of Orthopedics; 
Phillip R. Stevens, Bridgeport, WVU Depart- 
ment of Surgery; 

Jane E. Thrush, Morgantown, LTniversity of 
Pittsburgh Health Center Hospitals; Vincent C. 
Traynelis, Morgantown. WVU Department of 
Surgery; Michael B. Voorhees, Martinsburg, 
W heeling Hospital; Charles B. Voss, Wheeling, 
University of Hawaii Hospitals; James W. 
Wallace, St. Albans, CAMC; Mark R. Weiser, 
Parkersburg, Tripler Medical Center. Hawaii: 
Daniel W. Wilson, St. Marys, Wheeling Hospital: 
Cynthia A. Winger, Huntington, CAMC: Sanjay 
S. Yadav, St. Albans. Veterans Administration 
Medical Center, Long Beach, California; and 
John M. Zambos, Beckley. WVLf Department of 
Surgery. 


May, 1983, Vol. 79, No. 5 


xxiii 



Professional 
Liability Insurance 
Designed for 
West Virginia 
Physicians 

“The Association recommends 
its endorsed program to you for... 
your most considered review and 
attention.” 

Reprinted from The West Virginia Medical Journal, September 1981 



Your Association’s Professional Liability Insurance Program Includes: 


• A five-year market guarantee with Continental Casualty Company, 
CNA, the fourth-largest underwriter of professional liability 
insurance in the United States. 

• A consent to settle provision for doctors covered under the plan. 

• An in-state managing general agent, McDonough Caperton Shepherd 
Group, with offices located in five key West Virginia cities 

to provide risk management and technical expertise in professional 
liability matters. 

• A payment plan with no finance charges. 

• A profit-sharing mechanism. 

McDonough 

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Corporate Headquarters: One Hillcrest Drive, East, P O Box 1551, Charleston, WV 25326 Telephone (304) 346-0611 
With offices in; Beckley, Charleston, Fairmont, Parkersburg, Wheeling 


The West Virginia Medical Journal / 

Vol. 79, No. 6 June, 1983 

Hospices Are Developing In West Virginia: 
What Physicians Need To Know 


PETER C. RAICH, M. D. 

Professor of Medicine and Chief, Section of Hema- 
tology Oncology, West Virginia University School of 
Medicine, Morgantown 

RICHARD JOHN C. PEARSON, M. B.. M.P.H. 

Professor and Chairman , Department of Community 
Medicine, WVU School of Medicine 

RICHARD M. IAMMARINO, M. D. 

Professor of Pathology and Director, Clinical Labora- 
tories, WVU Medical Center; and President. Morgan- 
town Hospice, Inc. 


Hospice programs have grown rapidly within 
the United States during the past decade. West 
Virginia presently has five active hospice pro- 
grams, and four in various stages of activation. 
These programs are designed to provide care by 
health professionals and volunteers to incurably 
ill patients. Control of debilitating and demoral- 
izing symptoms allows patients to remain within 
their homes and family circle. Physicians can 
contribute significantly to the care and under- 
standing of such patients during the end stages 
of their illness. 

T Tospices came to be developed in response 
to a perceived problem: the process of 

dying was being mismanaged. Either too little 
was being done for the patient because the 
disease process ( usually cancer I was too far 
advanced for treatment to be effective, and there 
was a failure to appreciate that even when the 
disease was incurable the patient still needed to 
be cared for: or too much was done in a stub- 
born. last-ditch, no-holds-barred battle against 
the disease even when the prognosis was hopeless. 
That the problem was real has become obvious 


since approximately 600 hospices are active or 
are being developed in the United States today. 
This is all the more remarkable in that there 
were none 12 years ago. 

In West Virginia today there are five hospices 
active: in Martinsburg, Wheeling, Charleston. 
Huntington and Beckley; and there are four 
more developing in Morgantown. Clarksburg, 
Parkersburg and Putnam County (see Appen- 
dix I . 

History of Modern Hospice 

While there is a long history of institutions, 
usually church-related, where all kinds of sick 
people have been lovingly cared for, the rapid 
development of the hospice concept specifically 
for the terminally ill in the United States in 
recent years can be traced to two sources: tbe de- 
velopment of a research and teaching hospice in 
London. England, and the work of Dr. Elizabeth 
Kubler-Ross. Dr. Cicely Saunders, in a London 
hospital after the end of World War II, had 
been nursing a dying man who was an exile 
from his country and alone, and needed help 
with a whole range of personal matters before 
he could feel comfortable to die with his affairs 
in order. They discussed the shortcomings of 
the hospital services, and he left her funds to 
establish a better way of caring for the terminally 
ill. 1 She spent the next 20 years becoming pre- 
pared to open her hospice to put into practice 
their ideas, and act as a demonstration of what 
could be done. 

A year or two after this hospice opened, 
Doctor Kubler-Ross’ book. On Death and Dying, 
was published. 2 This book, which has become 


June, 1983, Vol. 79, No. 6 


115 


a classic, deals with a series of interviews Doctor 
Kubler-Ross carried out in a dying patient 
population at the University of Chicago. In the 
book, Doctor Kubler-Ross has characterized 
what she calls the five stages of dying, namely, 
“denial,” “anger,” “bargaining,” “depression.” 
and “acceptance.” 

Content of a Hospice Program 

Hospice care does not relate to a place but a 
concept of dealing with dying patients with 
dignity, openness and compassion to help them 
and their families reach “acceptance.” Although 
hospice programs take many forms, the most 
common one relates to a home care program 
administered by the small nuclear staff which 
coordinates services including skilled nursing 
care, care by nurse’s aides, medical social 
workers, ministers, and bereavement counseling 
services following the death of the patient. 

Hospice care is, of necessity, time-intensive. 
It takes many people several hours to establish 
a close relationship with the patients and their 
families. For this reason, hospice programs have 
had to rely heavily on trained volunteers for pro- 
vision of many of the services where discrete, 
medically defined skills were not necessary. The 
characteristics of a hospice program are itemized 
in Table l. 1 2 3 4 5 6 7 8 9 10 

Recent Federal Legislation 

Federal legislation was passed as a part of the 
Tax Equity and Fiscal Responsibility Act, 1982, 
that develops a mechanism for Medicare to pay 
for hospice care. However, the regulations that 
are being promulgated to implement this legisla- 
tion in November, 1983, have features that will 

TABLE 1 

Characteristics of a Hospice Program of Care 

1. Coordinated home care, with inpatient beds under a 
central, autonomous hospice administration. 

2. Control of symptoms (physical, sociological, psy- 
chological, and spiritual). 

3. Physician-directed services. 

4. Provision of care by an interdisciplinary team. 

5. Services available on a 24-hour-a-day, 7-day-a-week 
basis with emphasis on availability of medical and 
nursing skills. 

6. Patient and family regarded as a unit of care. 

7. Bereavement follow-up. 

8. Use of volunteers as an integral part of the inter- 
disciplinary team. 

9. Structured personnel support and communication 
systems. 

10. Patients accepted to the program on the basis of 
health needs, not ability to pay. 


make it financially impossible for any hospice 
in West Virginia, or in a rural area elsewhere 
in the country, to be able to participate. The 
regulations require the hospice: to provide 

directly and substantially all of the nursing care 
( hy an RN), the medical social services, 
and physician and counseling (bereavement, 
dietary and nutritional ) services; to retain super- 
vision and management responsibility, including 
central clinical records on all its patients; and to 
be liable for hospital bills for patients who 
incur bills greater than Medicare will pay. 

None of the West Virginia programs has the 
financial resources to handle these requirements. 
Hospice programs in West Virginia will therefore 
have to develop independently, and rely, at least 
to some extent, upon volunteer services and 
charitable contributions. 

Do’s and Don’ts for Physicians 

Following are some do’s and don’ts for 
physicians: 

1. Do get involved with the hospice move- 
ment. If there is a hospice in your community, 
see if there is any way that you can help. 

2. Do refer patients for their care. 

3. Don't be afraid that hospice personnel are 
not professional. Typically, individuals who 
work with a hospice are dedicated, and have had 
training to fulfill their roles. These roles do not 
replace physician services but amplify and 
complement them. 

4. Do be honest with your patients. If you 
believe that they are terminal, then the message 
needs to get across either to the patient or a 
family member so that realistic family planning 
can take place, and support from hospice can 
be had. 

5. Don’t withdraw just because you cannot 
care or even palliate. You can still help with 
symptom and pain control. 

Symptom Control 

Outlined below are two areas of symptom con- 
trol. 

I. Control of Pain in Cancer 

Because of the diverse causes of cancer- 
related pain, a number of treatment modalities 
may be useful and worthy of consideration in 
such patients (Table 2). Below we have selected 
and discussed in greater detail some of the com- 
monly used agents. 


116 


The West Virginia Medical Journal 


TABLE 2 

General Principles of Cancer Pain Management* 


Cause of Pain 

Primary Treatment 

Secondary Treatment 

To Consider 

VISCERAL: 

involvement of abdominal 
or pelvic organs 

Analgesics 

Low-dose steroids 

Celiac axis block for 
abdominal pain. Intrathecal 
block for pelvic pain 

BONE PAIN: 

Direct spread distant 
metastases 

1. Palliative radiotherapy 

2. Non-steroidal, anti- 
inflammatory drugs 

3. Immobilization: Cervical 
collar, pinning 

Analgesics 

Nerve block. Low-dose 
steroids 

SOFT TISSUE 
INFILTRATION 

Analgesics 

Low-dose steroids 

Nerve block 

NERVE COMPRESSION 

Analgesics 

High-dose steroids 

Nerve block 

SECONDARY 

INFECTION: 

1. Systemic antibiotics 
including metronidazole 
if possibility of 
anaerobes. Local surgery. 

2. Systemic antibiotics. 
Local applications, e.g., 
Providone, Iodine 

Analgesics 

Nerve block. Topical local 
anesthetics 

PLEURAL PAIN 

Antibiotics if appropriate 

Analgesics 

Intercostal block 

COLIC due to bowel 
obstruction 

Stool softeners. 
Antispasmodics, e.g., Lomotil 

Analgesics 


LYMPHEDEMA 

Intermittent positive pressure 
machine 

Analgesics. 

Jobst sleeve or stocking 

High-dose steroids 

HEADACHES from raised 
intracranial pressure 

High-dose steroids. Raise 
head of bed 

Avoid opiate analgesics 

Diuretics may help 

PAIN in paralyzed 
limb(s) 

Physical therapy and regular 
movement of limb(s) 

Non-steroidal anti- 
inflammatory drugs 

Muscle relaxants 


“Adapted from Ajemian I, Mount BM 6 


A. Non-narcotic analgesics. 

Aspirin and acetaminophen (Tylenol R ) are 
the most commonly used. They are equal 
in pain-relief activity. Both will decrease 
fever, but aspirin is a stronger anti-inflam- 
matory agent. Aspirin interferes with 
platelet function and may lead to gastritis. 
Pentazocine (Talwin R ) and codeine also 
are active agents for moderate pain, and 
potentiate the action of aspirin and 
acetaminophen when combined with these 
agents. However, pentazocine has bother- 
some gastrointestinal and central nervous 
system side-effects. Most of the newer 
class of non-steroidal, anti-inflammatory 
agents may be helpful in controlling 
cancer-related pain, along with other 
agents, especially in patients with metas- 
tases to bone. 

B. Narcotic Analgesics 

Codeine is an effective oral agent for 
moderate pain, and often is combined with 
aspirin and acetaminophen, but may be 


associated with constipation on prolonged 
use. For more severe and chronic cancer- 
related pain, more potent narcotic agents 
are usually required. The oral administra- 
tion of morphine sulfate has proven to be 
especially valuable, and lends itself well 
to home-care patients. 4 The oral-to- 
parenteral potency ratio of morphine is 
1:3. Although most patients’ pain is well 
controlled on oral doses of 10-30 mg. every 
four hours, in some patients as much as 
100 mg. per dose may be required. Initial 
drowsiness usually clears after the first 
three to five days. Morphine sulfate may 
be made up in simple solution or as a 
flavored syrup. Morphine may be given 
in combination with dextroamphetamine 
five mg. with each morphine dose, except 
at night, to reduce drowsiness. An anti- 
emetic or oxyphencyclimine (Vistaril R ) 
for anxiety, or amitriptyline (Elavil R ) for 
depression and sleeplessness also may be 
added. Most hospice programs no longer 


June, 1983, Vol. 79, No. 6 


117 


advocate the Brompton's cocktail type of 
mixtures. Methadone is an alternate potent 
oral narcotic analgesic and has the ad- 
vantage of a longer drug half-life. The 
usual dosage is five to 15 mg. every eight 
to 12 hours. If nausea and vomiting pre- 
clude oral analgesics, hydromorphone 
hydrochloride ( I)ilaudid R ) suppositories 
three mg. every four to six hours, are 
useful. 

C. Pain Control Without Drugs 

These measures may help to control milder 
pain, and when combined with analgesics 
may be used while waiting for pain medi- 
cations to take effect or during times of 
incomplete pain relief. Distraction methods 
include concentrating on slow, rhythmic 
breathing and singing or tapping. Relaxa- 
tion, imagery and skin stimulation with 
massage, pressure, vibration or menthol 
gels also may have an adjunctive role in 
pain control. 

II. Nausea and Vomiting 

Nausea and vomiting can be a major problem 
in cancer patients receiving cytotoxic chemo- 
therapy or radiation therapy, hut also may be 
secondary to the malignancy itself or its compli- 
cations.’’ Control of these symptoms frequently 
can he achieved with the proper selection and 
trial of a variety of effective anti-nausea agents. 
Th ese are usually available in oral, parenteral or 
suppository preparations. The following have 
been found to be especially useful in cancer 
patients. 

A. Phenothiazines — inhibit stimulation of 
the chemo-receptor trigger zone. 
Prochlorperazine (Compazine R ) five to 
10 mg. q. four hours. 

Chlorpromazine ( Thorazine R I 10 to 25 
mg. q. four hours. 

Triethylperazine (Torecan R ) 10 mg. tab. 
or supp. q. four hours. 

B. Antihistamines — diminish vestibular in- 
put, mildly sedating. 

Benadryl 25-50 mg. q.i.d. 

C. Halperidol I Haldol 1, I one to two mg. q. 
eight hours. 

Metoclopramide I Reglan R ) — used IV for 
cis-platinum-induced nausea. 

D. Corticosteroids — may be combined with 
effervescent phosphates. 

Prednisone at one mg/kg. dose is treat- 
ment of choice for hypercalcemia. 


Dexamethasone I Decardron R ) for vomit- 
ing secondary to raised intracranial pres- 
sure four mg. q.i.d. 

E. Tetrahydrocannabinol (THC) approved 
for use only with chemotherapy at present. 

F. Additional measures may be beneficial in 
patients with troublesome nausea and 
vomiting: 

1. Identify and eliminate cause where 
possible. 

2. Vomiting is often tolerated in the 
the absence of nausea. 

3. Frequent oral hygiene, especially after 
each emesis and prior to meals. 

4. Eliminate repulsive odors and sights. 

5. Bowel regulation. 

6. Frequent small bland feedings when 
desired, including carbonated bever- 
ages. 

7. Antiemetics one hour before meals. 

By the judicious use of these and other 
methods of symptom control the quality of life 
may be improved dramatically in such patients. 
Much can be done to help patients and their 
families during the terminal phase of illness. The 
hospice program merely allows for the proper 
blending of the skills of health professionals with 
the dedication of volunteers. 

‘‘Surely though the recovery of the patient 
be the grand aim of their I physicians’ ) pro- 
fession, yet where that cannot be attained, 
they should try to disarm death of some of 
its terrors, and if they cannot make him quit 
his prey, and the life must be lost, they may 
still prevail to have it taken away in the 
most merciful manner. ' 

William Heberden, 1710-1801 

Editors Note: Here are the generic drugs 

and trade names (in parentheses) to which 
reference is made in this manuscript : aceta- 

minophen I Tylenol); aspirin ; amitriptyline 
hydrochloride {Elavil); chlorpromazine (Thora- 
zine); codeine sulfate; dexamethasone I Decad- 
ron ) ; dextroamphetamine ( Obetrol ) ; diphen- 
hydramine hydrochloride (Benadryl); halo- 
peridol (Haldol); hydromorphine hydrochloride 
I Dilaudid); metoclopramide (Reglan); mor- 
phine sulfate; oxyphencyclimine (Vistaril) ; pen- 
tazocine ( Talivin ); prednisone; prochlorperazine 
( Compazine | ; tetrahydrocannabinol; and trie- 
thylperazine ( T ore can ) . 


118 


The West Virginia Medical Journal 


References 

1. Stoddard S: The Hospice Movement, New York, 
Stein and Day, 1978. 

2. Kubler-Ross E: On Death And Dying, New York. 
MacMillen, 1969. 

3. Lack SA, Buckingham III, RW: First American 
Hospice, New Haven, CT, Hospice, Inc, 1978. 

4. The Clinical Cancer Letter, 1982; 5(2):6-8. 

5. Seigel LJ, Longo DL: The control of chemo- 

therapy-induced emesis. Ann Int Med 1981; 95(3):352- 
359. 

6. Ajemian I, Mount BM (eds): The Roijal Victoria 
Hospital Manual on Palliative/ Hospice Care : A Resource 
Book, New York, Arno Press, 1980. 

Appendix 

Contact Persons for Hospices in West Virginia 

Hospice of Martinsburg, Inc. 

Mr. Larry Crawley-Woods 
Rt. 1, Box 211 

Martinsburg 25401 229-8886 

Clara Welty Hospice 

Mr. Larry Papi, Executive Director 

109 Main Street 

Wheeling 26003 232-3370 

Kanawha Hospice Care Inc. 

Ms. Beckv Bailey, R.N., Program Director 
P. O. Box 2013 

Charleston 25327 343-9843 


Hospice of Huntington, Inc. 

Mrs. Laura Darby, Volunteer Coordinator 
1600 S. Jefferson Drive 

Huntington 25701 429-1972 

Raleigh County Hospice Care 
Darrell Moore 
Box 1571 
Recklep 25801 

Morgantown Hospice, Inc. 

Marge Kearney, Executive Director 
1000 Van Voorhis Road 

Morgantown 26505 598-3424 

Hospice Association of Greater Parkersburg Area 
Mrs. Linda Dye, President 
Dudley Avenue 
Parkersburg 26101 

People’s Hospice, Inc. 

Del Parrish, President 
United Health Center 
Box 1680 
Clarksburg 26301 

Hospice of Putnam County' 

Ms. Robin Rogers, Secretary 
Rt. 3, Box 308-A 
Hurricane 25526 

Lewisburg Area Hospice Interest Croup 
Ms. Frances Doss, R.N. 

Denmar Hospital 
Hillsboro 24946 653-4201 


485-8216 


624-2265 


562-2646 


Teens’ Newborns Not Always Less Healthy 

A lthough teenage pregnancy is considered a major social problem in the United 
States, the newborns of teenage mothers are not necessarily less healthy than those 
of older mothers, according to two University of Michigan researchers. 

Newborns and infants of teenage mothers, although often weighing less than offspring 
of mothers in their 20s, actually score higher on some tests of early physical and mental 
development, write Stanley M. Garn, Ph D., and Audrey S. Petzold, from the Uni- 
versity’s Center for Human Growth and Development, in a recent issue of American 
Journal of Diseases of Children. 


June. 1983, Vol. 79, No. 6 


119 


Surgical Treatment Of The Subclavian 'Steal' Syndrome 


ALI F. ABURAHMA, M. D. 

Clinical Associate Professor in Surgery and Director, 
Noninvasive Vascular Laboratory, West Virginia Uni- 
versity Medical Center, Charleston Division 

WILLIAM E. LAWTON, JR., M. D. 

Clinical Associate Professor in Surgery, WVU Medical 
Center, Charleston Division 


Various procedures have been proposed for 
the treatment of subclavian “steal” syndrome, 
none of which has been uniformly accepted by 
vascular surgeons. The authors analyze their 
experiences with this problem with emphasis on 
axillary-to-axillary bypass for the surgical cor- 
rection of this disease. 

/^\F the patients with symptomatic subclavian 
“steal’’ syndrome who were corrected 
surgically at Charleston Area Medical Center 
between August, 1978, and February, 1982, 20 
were corrected either by axillary-to-axillary 
artery bypass I 12 patients) or carotid-to- 
subclavian bypass (eight patients). All other 
cases were excluded. 

Ten of the 12 axillary-to-axillary bypass grafts 
and two of the carotid-subclavian bypasses ( 12 
of 20 cases ) were done by our group. 



Figure la. A patient with complete occlusion of 
the left subclavian artery. 


Analysis of 12 Patients 

Ages range from 44 to 66 years. There were 
five males and seven females. 

Ten of our 12 patients had clinical symptoms 
of left subclavian “steal’’ (Figure 1). Tw'o of 
these had left arm claudication. Of the remain- 
ing two, one had right subclavian “steal” and 
the other had both right subclavian “steal” and 
right carotid “steal” secondary to innominate 
artery occlusion (Figure 2). All of these patients 
had an arm Doppler pressure difference of > 
15 mm. Hg and a weaker pulse on the diseased 
side. All patients are analyzed in the Table. 

Follow-up period ranged from three to 40 
months. 

Axillarv-to-Axillary Technique 

Two transverse incisions are made over the 
delto-pectoral grooves. The incision is deepened 
to expose the axillary artery, axillary vein and 
brachial plexus. The second portion of the 
axillary artery is isolated. An eight-mm Cortex 
graft is sutured in place in end-to-side fashion. 
The graft is placed underneath the pectoralis 
major and then through a tunnel which is made 



Figure lb. The same patient with left subclavian 

“steal.” 


120 


The West Virginia Medical Journal 


in the presternal subcutaneous tissue to the The distal end of the graft is then sutured to the 

contralateral axilla. The contralateral end of the other axillary artery in end-to-side fashion 

graft also is placed under the pectoralis major. (Figures 3a and 3b 1. 


TABLE 

Twelve Patients with Subclavian “Steal” Syndrome 


Case 

Age 

Sex 

Radiological 

Findings 

Operation 

Followup 
in months 

Complications 

Patency 

1 

62 

M 

Left subclavian stenosis 
with vertebral “steal” 

Axillary-axillary 

bypass 

24 

None 

Patent 

2 

64 

F 

” 

” 

23 

” 

tt 

3 

50 

F 


Left carotid 
subclavian bypass 

26 


tt 

4 

56 

F 


Axillary-axillary 

bypass 

40 


tt 

5 

54 

M 

” 


28 

” 


6 

44 

F 


Left carotid 
subclavian bypass 

32 


rt 

7 

62 

M 

Rt. subclavian stenosis 
with vertebral “steal” 

Axillary-axillary 

bypass 

27 

Parasthesia of hand- 
one week 

tt 

8 

66 

M 

Left subclavian stenosis 
with vertebral “steal” 


21 

None 

tt 

9 

59 

F 

Left subclavian stenosis 
with vertebral “steal” 

Axillary-axillary 

bypass 

18 


tt 

10 

63 

F 

” 

” 

12 


” 

11 

53 

M 

Innominate occlusion 
with right carotid and 
subclavian “steal” 


3 

Thrombosis & 
infection 

Removed 

12 

63 

F 

Left subclavian stenosis 
with vertebral “steal” 


5 

None 

Patent 



Figure 2a. A patient with complete occlusion of Figure 2b. The same patient with right carotid 

the innominate artery which showed right sub- “steal.” 
clavian “steal.” 


June, 1983, Vol. 79, No. 6 


121 




Carotid-to-Subclavian Bypass 

A transverse supraclavicular incision is made. 
The subcutaneous tissue, platysma and clavicular 
head of the sternocleidomastoid muscle are 
incised. The sternal head of sternocleidomastoid 
is retracted medially and the common carotid 
artery exposed and isolated. The scalenus anti- 
cus muscle is transected after isolation of the 
phrenic nerve. The subclavian artery is exposed 
and isolated. The graft is sutured to the sub- 
clavian artery in end-to-side fashion. The distal 
end of the graft is then anastomosed to the side 
of the common carotid artery (end to side) 

I Figure 4 ) . 

Results 

The results are summarized in the Table. All 
symptoms of subclavian “steal” and arm 
ischemia disappeared. The blood pressure be- 
came equal in both arms, and normal pulses were 
restored. There have been no complications in 
the two carotid subclavian bypasses ( 26 and 32 
months ) . One patient who had axillary-to- 
axillarv bypass had thrombosis of the graft three 
days after surgery. Thromboembolectomy was 
done but two months later infection necessitated 
removal of the graft. This case was an emergency 
axillary-to-axillary bypass for acute occlusion of 
the innominate artery with right subclavian and 
carotid “steal” with acute ischemia of the right 




Figures 3a (top) and 3b (bottom). Axillary-to- 
axillary artery bypass graft. 


arm. All other cases (90 per cent) are still 
patent. Patency rate was determined during 
five to 40 months' followup. There was no 
mortality in our series. 

Discussion 

This interesting syndrome was first described 
by the Italian radiologist, Contorni. 1 in 1960. 
Pieivieh et air presented the first two cases in 
American Literature in the New England Journal 
of Medicine (Editorial) A In this situation the 
proximal subclavian artery, usually the left, is 
occluded while the ipsilateral vertebral artery is 
patent. There is reversal of flow in the vertebral 
artery with blood flowing from the brain into the 
arm distal to the subclavian occlusion via the 
patent vertebral vessel. 

With loss of blood from the brain stem and 
cerebellum, one may have manifestations of 
vertebrobasilar insufficiency, e.g., vertigo, head- 
ache. bilateral visual disturbances, dysarthria, 
dysphagia, disorders of equilibrium, impairment 
of consciousness and drop attacks. There may 
be monoparesis or paralysis shifting from side 
to side and involving any or all of the extremities. 
Sensory defects on both sides of the body, 
cranial nerve paralysis, and cerebellar signs with 
ataxia also occur. These symptoms may be 
precipitated by exercise of the ipsilateral arm. 

Detailed serial arteriograms are necessary to 
establish the diagnosis of this syndrome. Unless 
symptomatic, patients with this syndrome need 
not be subjected to surgical correction. 



Figure 4. Carotid-to-subclavian bypass graft. 


122 


The West Virginia Medical Journal 


Current Surgical Modalities 

Technical procedures have changed consider- 
ably during the past decade. In the past, stenoses 
of the innominate and subclavian arteries were 
treated by direct endarterectomy or with bypass 
graft taking origin from the arch of the aorta. 
Although blood flow restoration was quite satis- 
factory, it soon became obvious that mortality 
and morbidity for these procedures were quite 
high ( 20-per cent mortality 1 . 4 

Consequently, new methods were devised for 
treating these lesions, resulting in the use of 
extrathoracic approaches and cervical bypass 
procedures almost routinely. These operations 
are simpler to perform, carry a low mortality 
and morbidity, and are quite satisfactory. 

1. Carotid-to-Subclavian Bypass: Its technique 
was described earlier (Figure 4). This pro- 
cedure was described first by North’ and associ- 
ates, and popularized by Diethrich. 6 

Advantages: 

A. Extrathoracic approach - — much less 
morbidity and mortality. 

B. The long-term patency rate is excellent. 

Diethrich et al. reported 125 patients with 
carotid subclavian bypasses followed from nine 
months to 14 years with a 4.8 mortality. Only 
two grafts failed ( one thrombosis and one in- 
fection ). 

Disadvantages: 

A. Possible vascular “steal” from the ipsi- 
lateral carotid artery. ,8 However, this point has 
been controversial; supporters of the procedure 
have pointed out both clinically and experi- 
mentally that there would be no “steal with this 
kind of procedure. 5,6 

B. The necessity of clamping the donor carotid 
artery while the proximal anastomosis is being 
performed. 

C. Possible cerebral embolization from the 
graft suture line. 

D. Stenosis of the carotid graft by kinking 
with neck motion. 

E. Rarely, injury to phrenic nerve or thoracic 
duct. 

F. The subclavian artery is usually a friable, 
thin-walled vessel, and may present technical 
difficulty in graft anastomosis. Blaisdell 9 re- 
ported a four-per cent incidence of central 
nervous system complications after carotid sub- 
clavian bypass. 


There was a total of eight cases of carotid 
subclavian bypass done at Charleston Area Medi- 
cal Center in the last three years. All these are 
still patent. 

2. Axillary-to- Axillary Artery Bypass: In 

1971, Myers et aid 0 first reported the use of the 
axillo-axillary bypass in revascularizing an upper 
extremity in a very-poor-risk patient. Since 
then, the reported experiences ( not including our 
12 I total 38 cases: 


Source 

Year 

Cases 

Myers et aid 0 

1971 

2 

Mozersky et aid 1 

1972 

3 

Jacobson et aid 2 

1973 

1 

Dardik & Dardik 1 

8 1974 

2 

Leveen et ald A 

1974 

1 

Snider et ald J 

1974 

6 

Lamis et aid 6 

1976 

9 

Myers et aid 

1979 

14 

AbuRahma et al. 

Present Series 

12* 


"These cases were done to both good- and 
high-risk patients. 

The results of all the reported experiences 
have been excellent with good restoration of 
antegrade flow in the recipient vessels and with- 
out evidence of a “steal from the donor vessel. 

Advantages: 

A. Extrathoracic. 

B. Simple. 

C. Does not require carotid manipulation. 

D. Does not require subclavian dissection 
( i.e.. will avoid injury to phrenic nerve, thoracic 
duct, etc.) 

E. Easy to palpate and follow. 

Disadvantages: 

A. Possible compression of the graft against 
the sternum; this is very rare. 

B. Needs careful dissection of the axillary 
artery to avoid injury to the brachial plexus. 
( That is why we select the second portion of the 
axillary artery as the donor site.) 

A total of 12 cases were treated at Charleston 
Area Medical Center, 10 of these by our group. 
There was no mortality or morbidity except in 
one case where thrombosis and infection 
occurred I three to 40 months’ followup). 

Subclavian artery transposition or implanta- 
tion into the common carotid artery could be 
done instead of the carotid-to-subclavian bypass. 


June, 1983, Vol. 79, No. 6 


123 



Figure 5. Case of complete occlusion of left subclavian artery which was corrected by subclavian artery 
transposition or implantation into the common carotid artery. 



The only difference here is that instead of using 
a graft, the distal end of the subclavian distal to 
the occlusion is anastomosed to the common 
carotid artery (Figure 5). It has the same ad- 
vantages and disadvantages of carotid subclavian 
bypass. 

Subclavian-to-subclavian artery bypass also 
can be done. In this procedure, both subclavian 
arteries are exposed, as described previously, by 
supraclavicular incisions (Figure 6). This pro- 
cedure was described briefly by Blaisdell el al. 9 
and Fhrenfeld et al . 18 in 1968 and 1969. 
Finkelstein et al. 19 reported the first 15 patients 
who had this procedure in 1972. He reported 
no mortality or morbidity in all 15 patients who 
were followed from six months to four years. 


Summary 

Various procedures have been proposed for 
the correction of symptomatic subclavian “steal” 



Figure 6. Subclavian-to-subclavian artery bypass. 


syndrome. Twenty cases of these were treated at 
Charleston Area Medical Center in the last four 
years: 12 with axillary-to-axillary artery bypass, 
and eight with carotid subclavian bypass. There 
was no mortality. One patient had thrombosis 
and infection of the graft, while the remaining 
19 had patent grafts (three to 40 months’ follow- 
up). All patients’ symptoms and signs were 
relieved. 

Axillary-to-axillary bypass currently is our 
procedure of choice for the correction of 
symptomatic subclavian “steal” syndrome. It 
appears to be the simplest to perform with the 
least potential complications. 

References 

1. Contorni L: The vertebro-vertebral collateral cir- 
culation in obliteration of the subclavian artery at its 
origin. Minerva Chir 1960; 15:268. 

2. Reivich M, Holling HE, Roberts B. Toole JF: Re- 
versal of blood flow through the vertebral artery and its 
effect on cerebral circulation. N Engl ] Med 1961; 
265:878. 

•3. Editorial: A new vascular syndrome— The sub- 

clavian “steal.” N Engl ] Med 1961; 265:912. 

4. Crawford ES. DeBakey ME, Morris GC Jr, Howell 
JF: Surgical treatment of occlusion of the innominate, 
common carotid and subclavian arteries. A 10-vear ex- 
perience. Surgery 1969; 65-17. 

5. North RR, Fields WS, DeBakey ME, Crawford ES: 
Brachial-basilar insufficiency svndrome. Neurology 1962; 
12:810. 

6. Diethrieh EB, Garrett HE, Ameriso J et al.: Oc- 
clusive disease of common carotid and subclavian arteries 
treated bv carotid-subclavian bypass. Am J Surg 1967; 
114:800-808. 

7. Dumanian AV, Frahm CJ, Pascale LR et al.: The 
surgical treatment of the subclavian “steal” syndrome. 
/ Thorac C.ardiovasc Surg 1965; 50:22. 


124 


The West Virginia Medical Journal 


8. Harper JA, Golding AL, Mazzli EA, Cannon JA: 
An experimental hemodynamic study of the subclavian 
“steal” syndrome. Surg Gynecol Obstet 1967; 124:1212. 

9. Blaisdell WV, Clauss RH, Galbraith JG et ah: 
Joint study of extracranial occlusion. IV. A review of 
surgical complications. JAMA 1969; 209-1889. 

10. Myers WO, Lawton BR, Sautter RD: Axillo- 

axillary bypass graft. JAMA 1971; 218:826. 

11. Mozersky DJ, Sumner DS, Barnes RW et al.: The 
hemodynamics of the axillo-axillarv bypass. Surg Gynecol 
Obstet 1972; 135:925-929. 

12. Jacobson JH, Mozersky DJ, Mitty HA et ah: 
Axillary-axillary bypass for the “subclavian steal” syn- 
drome. Arch Surg 1973; 106:24-27. 

13. Dardik H. Dardik I : Axillo-axillary bypass with 
cephalic vein for correction of subclavian “steal” syn- 
drome. Surgery 1974; 76:413-418. 


14. LeVeen HH, Piccone VA Jr, Diaz C et al.: A 
simplified correction of subclavian “steal” syndrome. 
Surgery 1974; 75:299-304. 

15. Snider RL, Porter JM, Eidemiller LR: Axillary- 
axillary artery bypass for correction of subclavian artery 
occlusive disease. Ann Surg 1974; 180:888. 

16. Lamis PA, Stanton PE, Hyland L: The axillo- 
axillary bypass graft. Arch Surg 1976; 111:1353. 

17. Myers WO, Lawton BR, Jefferson FR et ah: 
Axillo-axillary bypass for subclavian “steal” svndrome. 
Arch Surg 1974; 114:394. 

18. Ehrenfeld WK, Levin SM, Wylie EJ: Venous 

crossover bypass grafts for arterial insufficiency. Ann 
Surg 1968; 167:287. 

19. Finkelstein NM, Byer A. Rush BR: Subclavian- 

subclavian bypass for the subclavian “steal” svndrome. 
Surgery 1972; 71:142. 


Manuscript Information 

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Journal should be typewritten, triple-spaced, on one side only of firm (no 
onion skin or flimsy), standard letter sized ( 8 V 2 by 11 in.) white paper. 
Wide margins (at least IV 4 in. on left) should be left free of typing. On 
the first or title page should be shown the title of the article, the name (or 
names) of the author, and his degrees. Pages should be numbered consecu- 
tively, the page number being shown in the right upper corner along with 
the surname of the author. 

Where reference is made to generically-designated drugs, the first such 
reference must be followed by parentheses containing the most commonly 
known trade-name drug of that designation. In addition, a listing of all generic 
drugs mentioned in the article, with their trade-name equivalents, should 
appear at the end of the article. 

A short abstract summarizing the manuscript should be included. This 
should be typed in double space on a separate page. 

Authors are requested to submit a carbon copy with the original. 

Illustrations should be numbered and their approximate locations shown 
in the text. Each should be identified by placing on its back the author’s 
name, its number and an indication of its “top.” Drawings and charts in- 
tended for reproduction should be done in black (India) ink on pure white. 
Photographs should be on glossy paper and minimum of about 5 by 7 in. 
in size. Cost of printing black and white photos in excess of 4 will be billed to 
author, and no more than 25 references will be published free of charge 
to the author. A legend should be provided for each illustration and, preferably, 
attached to it. 

All scientific material appearing in The Journal is reviewed by the 
Editorial Board. Manuscripts should be mailed to The Editor, West Virginia 
Medical Journal, Box 1031, Charleston, W. Va. 25324. 


June, 1983, Vol. 79, No. 6 


125 




From the West Virginia University 
Medical Center 

Edited By 

Angel V asquez, M. D. 

Professor of Pediatrics 

and 

Irma H. Ullrich , M. D. 

Associate Professor of Medicine 


Ketotic Hypoglycemia 


Discussant: 

JOSEPH P. CATLETT 
Medical Student III 


Although its etiology is still unknown, ketotic 
hypoglycemia remains the most common cause of 
childhood hypoglycemia, representing 65 per 
cent of the cases. This disorder affects children 
predominantly between the ages of one and 1.5 
years, and remits spontaneously with increasing 
age, usually before eight or nine. These children 
are symptom-free between episodes. 

Clinically, one should suspect ketotic hypo- 
glycemia in any child older than one year with 
central nervous system symptoms, decreased 
blood sugar, and ketonuria in the absence of 
hepatomegaly. Ketotic hypoglycemia can be 
distinguished from hyperinsulinism with a glu- 
cagon challenge test performed after provocation 
of symptomatic hypoglycemia by fasting or ad- 
ministration of a high-fat, ketogenic diet. 

Treatment is relatively simple: administration 
of a high-carbohydrate, high-protein diet with 
extra feeds at bedtime, in conjunction with an 
early breakfast. This usually precludes the need 
for drug therapy. F or acute hypoglycemic epi- 
sodes, oral or intravenous glucose is quite effec- 
tive. 

Long-term prognosis is good. The risk of 
mental retardation and intelligence impairment 
is proportional to the degree of control and 
frequency of hypoglycemic episodes. 


A lthough its etiology is still unknown, ketotic 
hypoglycemia remains the most common 
cause of childhood hypoglycemia, accounting for 
65 per cent of the cases. This disorder affects 
predominantly children between the ages of one 
and 1.5 years, and remits spontaneously with 
increasing age, usually before eight or nine. 
These children are symptom-free between hypo- 
glycemic episodes. 

History 

Ross and Joseph first noted the combination of 
convulsions, hypoglycemia and ketonuria in 
1924. In 1964, Colle and Ulstrom performed a 
classic study on childhood hypoglycemia, and are 
quoted extensively throughout the subsequent 
and current literature. They studied children 
with recurrent episodes of symptomatic hypo- 
glycemia associated with ketonuria which oc- 
curred after a period of low carbohydrate intake. 
The hypoglycemia exhibited a minimal or no 
response to glucagon. 

Clinical Picture 

Clinically, a previously active, healthy child 
gradually develops lethargy, somnolence, hypo- 
tonia and, in extreme cases, coma and seizures 
after a period of fasting or low carbohydrate in- 
take. Vomiting is usually associated with hypo- 
glycemia. Blood glucose is usually 50 mg/dl, 
and can be as low as 18-20 mg/dl. The symptoms 
respond dramatically to oral glucose or, if the 
patient is unresponsive, to intravenous glucose. 


126 


The West Virginia Medical Journal 


These children generally have a history of being 
small-for-gestational-age infants, and of prema- 
turity. Physical examination is significant for 
the absence of hepatomegaly. 

In summary, the Colle and Ulstrom study il- 
lustrated the following characteristics of the dis- 
order. 1 

1 ) The patients appear to be in good health 
prior to attacks. 

2 ) The first attack rarely occurs before the 
age of 18 months. 

3 ) Attacks occur after a period of food de- 
privation. 

4) Ketonuria is associated with the hypogly- 
cemia. 

5 ) Response to glucose is prompt. 

6 ) Fasting hlood glucose levels are normal be- 
tween attacks. There is no hypoglycemia after 
glucose loading. When the patient receives a 
normal diet, glycogen stores are present after a 
12-hour fast, and are discharged in response to 
glucagon and/or epinephrine. 

7 ) Most children are normal or near normal in 
intelligence; attacks tend to decrease in fre- 
quency as they become older. 

8) The children are below the fifteenth per- 
centile in both height and weight but are more 
retarded in weight than in height. 

Differential Diagnosis 

The differential diagnosis of childhood hypo- 
glycemia involves a number of complex disorders 
which can usually be ruled out by history, physi- 
cal examination and laboratory data. Explaining 
each of these cases is beyond the scope of this 
paper and can be found in any good pediatric 
text. A basically complete list follows: 5,6 


A. Hyperinsulinemia — ruled out by negative 

response 

to intramuscular glucagon 

1) 

Beta cell hyperplasia 

2) 

Islet cell adenoma or adenocarcinoma 

3) 

Nesidioblastosis (hyperplasia of the 
cells of Islets of Langerhans) 

4) 

Extra-pancreatic tumors 

5 ) 

Beckwith-Wiedemann syndrome 1 mac- 
roglossia. macrocephaly, hepatomegaly, 
somatic giantism, omphalocele) 

6l 

Prediabetes 

7) 

Leucine sensitivity 

8) 

Maple syrup urine disease 

9) 

Idiopathic 


B. Substrate limited 

1 ) Ketotic hypoglycemia — represents 65 
per cent of all childhood hypoglycemia, 
characterized by hypoglycemia with 
ketonuria, glucagon resistance, and 
small-for-gestational-age infants 

2 ) Glucagon deficiency 

3) Primary liver disease 

4) Catecholamine insufficiency (Zetter- 
stron syndrome) 

5 ) Endocrine deficiencies ( growth hor- 
mone, cortisol, etc.) 

C. Enzyme defects 

1 ) Glycogen storage disease — hepato- 
megaly and growth failure 

a. Glucose - 6 - phosphatase 

b. Amylo - 1.6 - glucosidase 

c. Defects of the phosphorylase cascade 
system 

2 ) Cluconeogenetic enzyme defects — 
Fructose - 1.6 - diphosphatase 

3 ) Other enzymatic defects 

a. Glycogen synthetase — clinical pic- 
ture similar to ketotic hypoglycemia 

b. Galactose - 1 phosphatase 

c. Fructose - 1 phosphate aldolase. 

D. Due to drugs and toxins 

1 ) Ethyl alcohol 

2 I Salic vlates and Tylenol f1T) 

3 I Sulfonylureas 

4 ) Propranolol 

5 I Jamaican vomiting sickness 

E. Other 

1 ) Hepatic damage 

a. Reye’s syndrome 

b. Leukemia 

2 ) Malabsorption 

3 I Renal glycosuria 

4 ) Malnutrition 

a. Kwashiorkor 

b. Low phenylalanine diet 

These diagnoses can be excluded by history, 
examination and laboratory studies. Ketotic 
hypoglycemia, hyperinsulinism and glycogen 
synthetase deficiency present similar pictures and 
have to be differentiated. In order to distinguish 
ketotic hypoglycemia from hyperinsulinism, the 
diagnosis is confirmed by provoking symptomatic 
hypoglycemia with fasting or by administration 


June, 1983, Vol. 79, No. 6 


127 


of a high-fat, ketogenic diet. 4 A glucagon chal- 
lenge test is then performed. 3 This involves a 
24-hour fast with prior baseline blood glucose 
and insulin levels determined. Subsequently, 
blood glucose and urine ketones (by Acetest) are 
determined at four-hour intervals. When the 
blood glucose level falls to 50 mg/ dl ( usually 12- 
24 hours later), glucose and insulin levels are 
drawn. Usually, in ketotic hypoglycemia, keto- 
nuria develops after less than 6-8 hours of fast- 
ing. followed by the appearance of symptomatic 
hypoglycemia between 12-24 hours. The fast is 
ended with a one-mg intramuscular injection of 
glucagon, and blood glucose levels are obtained 
at five, 10 and 15 minutes after injection. Hypo- 
glycemia that does not respond to glucagon is 
virtually diagnostic of ketotic hypoglycemia. In- 
sulin levels are within normal limits (normal 
fasting insulin levels 10-30 IU/ml). 

Note that the clinical picture of glycogen syn- 
thetase deficiency is similar to that of ketotic 
hypoglycemia, and also has a minimal response 
to glucagon. 3 Assay of hepatic glycogen syn- 
thetase can be used to differentiate, but among 
patients labeled ketotic hypoglycemia, persistent 
hyperglycemia and increase in serum lactate con- 
centration after administration of glucose should 
reveal those with possible deficiencies of glycogen 
synthetase. This latter disorder, however, is ex- 
tremely rare. 

Etiology and Pathogenesis 

Failure to decrease glucose utilization in re- 
sponse to fasting or a ketogenic diet appears to 
be the main cause of hypoglycemia in these 
children. The disorder remits spontaneously with 
increasing age. usually before eight to nine when 
glucose production per kilogram body weight is 
beginning to decrease toward adult values. 2 Using 
stable isotopically-labeled glucose, it has been 
demonstrated that the glucose production rate 
per kilogram of body weight during early child- 
hood is 2-4 times greater than in adults. 2 

The lack of response to glucagon at the time of 
symptoms suggests depletion of liver glycogen 
stores. Circulating alanine, the primary gluco- 
neogenic amino acid, is low. There is, however, 
no abnormality in the gluconeogenic pathway. 


Certain hypotheses have been put forth for eti- 
ology. 2 Briefly they are: 

1 ) a primary defect in the catecholamine re- 
sponse to hypoglycemia. 

2 ) a primary defect in the muscle protein 
catabolism during starvation leading to unavail- 
ability of gluconeogenic substrates, mainly 
alanine. 

3 ) a primary defect in the cortisol response 
during hypoglycemia. 

Treatment and Prognosis 

Intravenous glucose is administered to pa- 
tients experiencing acute hypoglycemic episodes 
who are unresponsive to oral glucose: the symp- 
toms remit rapidly. In the interim, a high- 
carbohydrate. high-protein diet administered with 
extra feeds at bedtime in conjunction with an 
early breakfast usually precludes the need for 
drug therapy. Parents also are instructed to 
monitor urine for ketones every morning and 
evening I and every four hours if the child is ill 
and has had decreased carbohydrate intake) 
since ketonuria is the harbinger of a hypogly- 
cemic episode. If ketonuria is present, liquids 
containing high concentrations of glucose should 
be administered. 

Long-term prognosis is good. Risk of mental 
retardation and intelligence impairment is pro- 
portional to the degree of control and frequency 
of the episodes. An association of delayed speech 
has been reported in ketotic hypoglycemics but 
this is a topic for further research. Some reports 
also have linked this disorder to an increased risk 
of developing diabetes mellitus, but this also is an 
avenue for further research. 

References 

1. Colie E, Ulstrom R et aL: Ketotic hvpoglvcemia. 
J Pcdiatr 1964; 64:632-49. 

2. Dahlquist G et aL: Ketotic Hypoglycemia of child- 
hood— A clinical triad of several unifying etiological hypo- 
theses. Acta Paediatr Scand 1979; 68:649-56. 

3. Finegold DN et aL: Glycemic response to glucagon 
during histing hypoglycemia: An aid in the diagnosis of 
hyperinsulinism. J Pediatr 1980; 96:257-9. 

4. Frasier SD: Pediatric Endocrinology , San Fran- 

cisco, Grune and Stratton, 1980, pp 305-7. 

5. Kempe CH et aL: Current Pediatric Diagnosis and 
Treatment, Los Altos, CA, Lange Medical Publications, 
1976, pp 639-667, 902-9. 

6. Vaughn VE et aL: Nelson’s Textbook of Pediatrics, 
Philadelphia, Sanders, 1979, pp 1603-4. 


128 


The West Virginia Medical Journal 




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J 


June, 1983, Vol. 79, No. 6 


129 




*jke PzeAident 



ON BECOMING INVOLVED 


“T7 very man owes part of his time and money 
to the business or industry in which he is 
engaged. No man has a moral right to with- 
hold his support from an organization that is 
striving to improve conditions within its 
sphere .” — Teddy Roosevelt. 

The above quote is especially applicable to 
the professions, and to our profession of 
Medicine in particular. Through the years, 
physicians have enjoyed a certain respect, al- 
most a reverence not accorded to many. There 
has been reason for this. It has been earned 
by dedication to the welfare of the patient 
above all else. The past generations of our 
peers have handed us a legacy built on their 
self-sacrifice and personal dedication to the 
good of the patient. This legacy has sustained 
our profession. 

Regrettably, this may no longer be true. 
Our profession is under attack from all sides 
as being cynical, uncaring, greedy and unin- 
volved. There seems to be a feeling rampant 
across the country and our state that physi- 
cians are interested only in taking from their 
patients and the community and giving very 
little in return. I think this is a false percep- 
tion, but it is a far cry from the image of 
Medicine as the compassionate, caring pro- 
fession it historically has been. 

We can correct this perception, I feel, by 
becoming more involved, as individuals and 
through our organization. It is not enough in 
our Association to say, “Let Charlie do it” 
(or Harry, or John, or Carl). We each must 
take an active interest and become involved 
in the efforts of our Association. It is not 


enough, in the political arena, to complain 
bitterly among ourselves when legislation 
contrary to the best interests of our patients 
is enacted. We each must take it upon our- 
self to investigate the issues, and com- 
municate our concerns to our legislators in- 
dividually so that they have some knowledge 
of the impact of their actions. Those actions 
that benefit our patients will, in the long run, 
benefit our profession. It may be a cliche to 
say, “If you are not part of the solution, you 
are part of the problem,” but there does ap- 
pear to be truth in this. 

We also need to become more involved, per- 
sonally and professionally, with our com- 
munities. Nowhere else is John Donne’s 
comment, “No man is an island . . . ,” more 
appropriate. If we physicians are perceived 
as a “privileged class” and as takers, not 
givers, each individual instance becomes a 
reflection on the profession as a whole. 

I ask and urge each of you, individually, to 
become more involved. The whole is greater 
than the sum of all its parts. Any actions of 
our organization are the results of the ac- 
cumulation of individual actions by con- 
cerned, dedicated physicians; and, if more of 
us will become more involved and act, the 
greater influence we can wield for the benefit 
of our patients. 



cv 




Harry Shannon, M. D., President 
West Virginia State Medical Association 


130 


The West Virginia Medical Journal 


The Vest Virginia tledical Journal 

Editorials 

The Publication Committee is not responsible for the authenticity of opinion or statements made by authors or 
in communications submitted to this Journal for publication. The author shall be held entirely responsible. 
Editorials printed in The Journal do not necessarily reflect the official position of the West Virginia State 
Medical Association. 


For some very practical reasons, state legisla- 
tive sessions hardly are models of consistency. 
In spite of what many might think. 60 days is not 
a long time in which to deal 
INCONSISTENCY adequately with budget and 
other complex matters, par- 
ticularly in the current era. 

As a result of this, political and other very 
real factors, things happen, and bills are passed, 
that often go outside the realm of logic. This 
was the case in 1983 in the general arena of 
health care costs. 

In a near-panic, last-minute move, the Legis- 
lature set up a West Virginia Health Care Cost 
Review Authority and empowered it to — among 
other things — set hospital rates. This Association 
regards the act as a poor piece of legislation, for 
reasons already expressed in The Journal and 
otherwise. 

But while it frantically moved to pass this 
cumbersome piece of so-called cost containment, 
the Legislature also enacted in its closing hours 
two other measures that promise to increase 
health care outlays. 

One requires accident and sickness insurers to 
make available coverage for primary health care 
nursing services, and thus provides the mecha- 
nism sought by the West Virginia Nurses As- 
sociation to help registered nurses — irrespective 
of levels of training — to move into independent 
practice. 

The other act makes physical therapists direct 
primary care providers by permitting them to 
treat persons other than those referred by doc- 
tors of medicine and osteopathy, dentists and 
podiatrists. State law previously has had the 
referral requirement. 

The inconsistency in the legislative action is 
clear. We have our doubts as to what the effects 
of the hospital act really will be. But we know 
of no evidence to indicate that creation of new 
primary care providers can do anything but 
increase the cost of health care to the public. 

With respect to the nurses measure, we think 
the public can expect to pay increased insurance 
premiums for the new coverage, effective next 


January 1. The insurance industry feels that 
some companies might not want to make the 
nurses coverage available, and elect to leave the 
state. That remains to be seen, of course, but 
West Virginia now is unique with this type of 
coverage as a part of statute. 

It’s also uncertain just how many nurses or 
groups of nurses might enter independent prac- 
tice. But with any number at all in such posture, 
and physical therapists in a generally similar role 
of independence, the picture is clear. More peo- 
ple will be after the health care dollar. 

We must hasten to stress that the Medical 
Association is not anti-nurse or anti-therapist. 
It has had a working committee relationship with 
the nurses association for years, and there’s no 
indication that will change. 

Perhaps it’s most fitting, at the moment, to 
recall the words a few years ago of the late Miss 
Freda Engle, the veteran executive officer of the 
West Virginia Board of Examiners for Registered 
Professional Nurses. 

The health care system. Miss Engle empha- 
sized, is just that — a system. Within that system 
are appropriate roles for the significant variety of 
health care providers, according to their expertise 
and training. But the system is of overriding im- 
portance. 

It has been in that general context that the 
Medical Association has worked for several years 
with the nurses’ examining board in specific 
efforts to develop administrative rules, regula- 
tions and realistic guidelines for the most effec- 
tive use of advanced registered nurse prac- 
titioners. 

It’s also significant, perhaps, that in this de- 
tailed effort the nurses’ board often has found 
physician comments and suggestions more rea- 
sonable than those from many nurses — partic- 
ularly those who don't have the training enjoyed 
by those with advanced degrees. 

There’s the further fact of life that to an ever 
increasing degree, additional persons and groups 
are struggling to get a bigger piece of the health 
care turf. 


• X 


June, 1983, Vol. 79, No. 6 


131 





It’s disturbing and frustrating — and even 
frightening when one considers the basic element 
of availability of quality care — to see legislative 
action which encourages and even directly con- 
tributes to this effort — again, irrespective of edu- 
cational and other provider qualifications. 


It can be said in many ways, but it can't be 
reemphasized too often. “It” is a national issue 
of the moment — the critical necessity for more 
and more involvement of physicians in public 
affairs. 

“Complaining about the actions of our elected 
representatives must be the second most popular 
indoor sport in our country.' ob- 
TAKE ACTION served Darrell Cannon. M. D.. 

the Los Angeles County Medical 
Association President. “But what they need 
from us now,” Doctor Cannon added, “is input, 
not complaints.” 

“Physicians could (emphasis ours) have a 
profound effect on all important issues,” the 
Nebraska Medical Association President, Allan 
C. Landers, M. D., recently wrote. “To fail to 
do so is to sacrifice a privilege we and our fore- 
bearers have earned.” 

Doctor Landers stressed that he was not re- 
ferring “to strictly medical issues, but to any 
issue that affects all citizens. I would encourage 
individual input into all levels of government, 
spanning the spectrum from local school boards 
right up through the Congress of the LInited 
States.” 

The Nebraska physician then zeroed in on one 
of the most pertinent points. “ Others , perhaps 
less informed, do it. Why shouldn’t we?” 

The Medical Association of the State of Ala- 
bama President, Ronald E. Henderson, M. D., 
noted the “multitude of dangers and opportun- 
ities facing the medical profession at the present 
time. The threat to the independent practice of 
medicine is real.” He added: 

“Because of the magnitude of change about to 
occur, there is the danger that the system that 
evolves will represent a threat to the patients 
that we serve. On the other hand, however, never 
before in your lifetime or mine has there been 
such an opportunity to make meaningful contri- 
butions.'' 

Nothing these physicians from other states 
have said is new. Our State Medical Association 
leadership has emphasized the same general 
points. But getting real action, in the form of 
individual and collective physician response, re- 
mains the critical problem in West Virginia, and 
elsewhere. 


Contact with legislators, for example, is a 
year-around necessity. Little really can be ac- 
complished during the short 60 days of an actual 
legislative session. 

Doctor Cannon urged the Los Angeles physi- 
cians to take the time and make the effort to 
meet legislators from their areas. Write or call 
them about issues that are of concern. And do 
this regardless of the calendar. 

“Our legislators are trying to resolve major 
problems,” Doctor Cannon said. “They will pro- 
duce better answers for all of us — doctors and 
patients — if we take the time and make the effort 
to keep them informed of our opinions and con- 
cerns on medical issues.” 

Again, there is nothing new nor revolutionary 
in this statement. But it sets forth a critical fact 
of life. Without much more physician involve- 
ment in the world outside the office or hospital. 
Medicine and quality medical care face an un- 
certain, and perhaps disastrous, future. 

Dwight L. Blackburn. M. D., President of the 
Kentucky Medical Association, put that same 
conclusion this way: “The ultimate survival of 
our profession and its ability to endure and serve 
succeeding generations is a responsibility each 
of us must continue to share.” 

Think about all this. And then do something 
about it. It’s time and effort you cannot afford 
not to find and undertake. 


This is June. Next comes July. And then 
August, with the Medical Association’s 116th 
Annual Meeting. Hopefully, particularly noting 
the embattled position in which Medicine and 
patient care now are entrenched, physicians 
around the state will think more about August 
25-27. 

Those physicians can have, through their local 
society memberships, 154 delegates in the As- 
sociation's House of Delegates. 
HELP WANTED This is the policy-making body 
— potentially the key com- 
ponent in organized Medicine here. 

In recent years, component societies have 
been slow to choose their delegates. Representa- 
tion at the Greenbrier has been nothing to write 
home about. All of which means that the issues 
can't be addressed unless the grass-roots member- 
ship does its part. 

Selection of delegates lias been slow again 
this year. Local societies need to pick up the 
pace. The State Association's leadership must 
have this kind of help and input if it is to be 
effective. 


132 


The West Virginia Medical Journal 


GENERAL NEWS 


Internist, Urologist Speakers 
For Convention Session 

Physicians from Washington, DC, and Akron, 
Ohio, will participate in a “Symposium on 
Sexually Transmitted Diseases” during the 116th 
Annual Meeting of the State Medical Association. 

Edmund C. Tramont, M. D., Chief, Infectious 
Diseases, Department of Bacterial Diseases, Wal- 
ter Reed Army Institute of Research in Wash- 
ington, will speak on “Syphilis and Gonococcal 



Edmund C. Tramont, M. D. Jack L. Summers, M. D. 

Infections,” while Jack L. Summers, M. D., of 
Akron will discuss “Sexual Mores in the 1980s.” 
Doctor Summers is full-time Chairman of the 
Department of Urology at Akron City Hospital 
and Professor and Chairman, Department of 
Urology, at Northeastern Ohio Universities Col- 
lege of Medicine in Akron. 

The symposium will constitute the first general 
scientific session of the convention Friday morn- 
ing, August 26. 

The Annual Meeting will be held August 25- 
27 at the Greenbrier in White Sulphur Springs. 

Other symposium speakers, as announced 
previously, will be Lee P. Van Voris, M. D., of 
Erie, Pennsylvania, until recently Associate Pro- 
fessor of Medicine at Marshall University and 
now Chief of Infectious Diseases and Hospital 
Epidemiologist at Hamot Hospital in Erie; and 
George J. Pazin. M. D., Associate Professor of 
Medicine at the University of Pittsburgh. Their 
topics, respectively, will be “Non-Luetic, Non- 
Gonococcal Venereal Diseases” and “Transmissi- 
ble Diseases of the Gay Patient.” 


AM A President to Speak 

The Annual Meeting will open with a pre- 
convention session of the Association’s Council 
and the first session of the House of Delegates on 
Thursday morning and afternoon, August 25; 
and end with the second and final House session 
and reception for new Association officers on 
Saturday morning and afternoon. 

Dr. Frank J. Jirka. Jr., of Barrington, Illinois, 
as announced previously, will address the first 
House session on Thursday. He will be installed 
as President of the American Medical Associa- 
tion this month in Chicago. 

Doctor Tramont, a colonel in the U. S. Army 
Medical Corps, also is Associate Professor of 
Medicine and Coordinator (Chief I, Division of 
Infectious Diseases, Uniformed Services Uni- 
versity of the Health Sciences Medical School, 
Bethesda, Maryland; and Clinical Associate Pro- 
fessor of Medicine at Georgetown LJniversity in 
Washington. 

He is a Fellow of the American College of 
Physicians and the Infectious Disease Society of 
America, a Diplomate of the American Board 
of Internal Medicine, and also a Diplomate, in 
Infectious Diseases, of that Board. 

Doctor Tramont was graduated from Rutgers 
University, and received his M. D. degree in 
1966 from Boston University. He took his post- 
graduate training at Bellevue (Cornell Division) 
and Memorial hospitals in New York City, and 
at Walter Reed. 

Doctor Tramont is the author or co-author of 
some 75 scientific articles and abstracts, plus a 
number of book reviews. 

WVU Graduate 

Doctor Summers is a 1966 graduate of West 
Virginia University School of Medicine, and 
served his internship and urology residency at 
Akron City Hospital. 

He was in the private practice of urology from 
1973 to 1979, at which time he became full-time 
Chairman of the Department of Urology at Akron 
City Hospital. Doctor Summers also is Clinical 
Professor of LIrology at WVU. He currently is 
President of the Cleveland Urological Society and 



June, 1983, Vol. 79, No. 6 


133 



President Elect of the Summit County Medical 
Society, Akron. 

Doctor Summers is pursuing a degree in sex 
education at the Institute for the Advanced Study 
of Human Sexuality in San Francisco. 

Dr. Samuel P. Asper of Philadelphia, also as 
announced, will deliver the keynote Thomas L. 
Harris address during opening exercises Friday 
morning preceding the first general scientific ses- 
sion. Doctor Asper, who is President of the 
Educational Commission for Foreign Medical 
Graduates, will speak on “Strengths and Weak- 
nesses of the U. S. Role in International Medi- 
cine. 

The second and final general scientific session, 
a “Symposium on Cardiovascular Diseases,” will 
be held Saturday morning. Individual subjects 
will include new developments in the manage- 
ment of cardiac arrhythmias; an update relative 
to cardiovascular surgery; and the management 
of congestive heart failure. 

Doctor Adkins To Be Installed 

At the final House session on Saturday after- 
noon, Carl R. Adkins, M. D., of Fayetteville will 
he installed as the Association’s 1983-84 Presi- 
dent to succeed Harry Shannon, M. D., of Park- 
ersburg. 

In addition to the House and general sessions, 
the Annual Meeting agenda will include break- 
fast, luncheon and other programs arranged by 
specialty societies and sections, many of which 
also will provide scientific discussions. 

The specialty group meetings will be held in 
large measure on Friday, with a few to be set 
for Saturday morning, preceding the second 
general session, and at noon. 

The Auxiliary to the State Medical Associa- 
tion, with Mrs. Richard S. Kerr of Morgantown 


Greenbrier Reservations 
Due By July 10 

Reservations for the 116th Annual Meeting 
of the West Virginia State Medical Association 
should be made with the Greenbrier no later 
than Sunday, July 10, in order to comply with 
the hotel’s requirement that all reservations 
must be received no later than 45 days prior to 
the meeting. Reservation forms provided by 
the Greenbrier have been distributed to all 
Association members. Any physicians who 
need additional forms should write or call the 
Association’s headquarters office in Charles- 
ton. 


the current President, as usual will hold its 
meeting in conjunction with that of the Associa- 
tion. 

Members of the 1983 Program Committee 
are David Z. Morgan. M. D., Morgantown, 
Chairman; Doctor Adkins; Jean P. Cavender, 
M. D., Charleston: Michael J. Lewis, M. D., St. 
Marys; Kenneth Scher, M. D., Huntington, and 
Roland J. Weisser, Jr., M. D., Morgantown. 

Information concerning remaining speakers 
and other convention details will be provided 
in the July and August issues of The Journal. 


Child Abuse, Drunk Driving 
Auxiliary Targets 

Promoting awareness and prevention of child 
abuse and drunk driving will be the focus of the 
American Medical Association Auxiliary’s 1983- 
84 Shape Up for Life campaign. 

In 1979, the AMA Auxiliary launched Shape 
Lip for Life, its nationwide program to promote 
good health. The Shape Lip for Life campaign 
encompasses areas of health such as nutrition, 
exercise, stress management, and substance 
abuse. 

In 1983-84, Shape Up for Life will focus on 
Children and Youth, with a special emphasis on 
prevention of child abuse. Drunk driving also 
will be spotlighted under the Shape Up for Life 
umbrella. Promotion of public awareness is the 
major concern, with new materials available to 
provide information. Two new brochures, en- 
titled “Child Abuse Prevention” and “Drinking 
and Traffic Safety,” will be available. 



Shown above at its April meeting is the Mason 
County Medical Society, which has become in- 
creasingly active in recent months. At the head of 
the table is Dr. Mel P. Simon, Point Pleasant 
urologist. President. The meeting was held at 
Pleasant Valley Hospital in Point Pleasant. 


134 


The West Virginia Medical Journal 


Continuing Education 
Activities 


Here are the continuing medical education 
activities listed primarily by the West Virginia 
University School of Medicine for part of 
1983, as compiled by Dr. Robert L. Smith, 
Assistant Dean for Continuing Education, and 
J. Zeb Wright, Ph. D., Coordinator, Con- 
tinuing Education, Department of Community 
Medicine, Charleston Division. The schedule is 
presented as a convenience for physicians in plan- 
ning their continuing education program. (Other 
national, state and district medical meetings are 
listed in the Medical Meetings Department of 
The Journal. ) 

The program is tentative and subject to 
change. It should he noted that weekly confer- 
ences also are held on the Morgantown, Charles- 
ton and Wheeling campuses. Further information 
about these may be obtained from: Division of 
Continuing Education. WVU Medical Center. 
3110 MacCorkle Avenue, S. E., Charleston 
25301: Office of Continuing Medical Education, 
WVU Medical Center, Morgantown 26506; or 
Office of Continuing Medical Education, Wheel- 
ing Division. WVU School of Medicine. Ohio 
\ alley Medical Center. 2000 Eoff Street. Wheel- 
ing 26003. 

June 3-4. Morgantown. Anesthesia Update 83 

June 4, Charleston. 10th Annual Wildwater 
Conference — Medical & Surgical Update 

June 11. Morgantown, Interventional Radiology 

Regularly Scheduled Continuing 
Education Outreach Programs from 
WVU Medical Center/ 
Charleston Division 

Buckhannon, St. Joseph’s Hospital, first-floor 
cafeteria. 3rd Thursday. 7-9 P. M. — June 
16. ‘‘Sudden Infant Death Syndrome. David 
Myerherg, M. D. 

Cabin Creel r. Cabin Creek Medical Center, 
Dawes, 2nd Wednesday, 8-10 A. M. — June 
8, ‘‘ENT Update. ' Ronald L. Wilkinson. M. D. 

Cassaway , Braxton Co. Memorial Hospital, 1st 
Wednesday. 7-9 P. M. — June 1, “Common 
Blood Disorders.” Steven Juhelirer, M. D. 

July 6. “The Pharmacology of Hypertension 
Management,” Stephen Grubb. M. D. 


Aug. 3, “Diagnosis of Pulmonary Disorders,” 
Dominic Caziano, M. D. 

Madison , 2nd floor, Lick Creek Social Services 
Bldg., 2nd Tuesday, 7-9 P. M. — June 14. 
“Recently Recognized Sexually — Transmitted 
Diseases.” Thomas W. Mou, M. D. 

July 12, “Approach to the Peripheral Vascular 
Patient. " Ali F. AbuRahma. M. D. 

Oak Hill, Oak Hill High School ( Oyler Exit, N 
19 1 4th Tuesday, 7-9 P. M. — June 28. 
“Protocols for the Treatment of Pit Viper 
Bites,” David Wright. VI. D. 

Welch, Stevens Clinic Hospital, 3rd Wednesday, 
12 l\oon-2 P. M. — June 15, “Low Back 
Injury” la special program in cooperation 
with Workers’ Compensation Fund of W. \ a., 
speaker to be announced ) 

W hitesville, Raleigh-Boone Medical Center, 4th 
Wednesday, 11 A. M.-l P. M. — June- August 
I summer break ) 

Williamson, Appalachian Power Auditorium, 1st 
Thursday, 6:30-8:30 P. M. — June 2. “Proper 
Utilization of the Clinical Laboratory. Bobby 
Lee Caldwell, M. D. 


Management / Lai) Workshops 
June 16-17, Beckley 

Health delivery management, intestinal para- 
sitology. and abnormal white/red blood cell 
morphology will be the three workshop subjects 
for the Summer Management Laboratory Con- 
ference June 16-17 in Beckley at the Ramada 
Inn. 

Sponsors are Hygeia Facilities in Oceana 
and West Virginia University Medical Center, 
Charleston Division. 

The two-dav parasitology wet workshop will be 
conducted by John E. Hall. Ph.D.. Professor of 
Microbiology. WVU Medical Center. The hema- 
tology workshop, a seven-hour option on the 
17th. will be led by William Koss, M.D., Director 
of Hematology and Coagulation Laboratories; 
Marta J. Henderson. M.S., Department of 
Medical Technology: and Deborah A. Jones 
VlTlASCPl, Hematology Laboratory, all from 
the WVU Medical Center. 

The one-day management workshop on June 
16 will be conducted by Albert E. Giles and Jon 
V. Straumfjord, M. D., Ph.D., Kirkwood, New 
Jersey. Current Medicare-Medicaid legislation 


‘ X 


June, 1983, Vol. 79, No. 6 


135 





will be among laboratory management topics 
covered. 

A total of .7 Continuing Education Unit 
(CEU ) Credits may be earned each of the two 
days. All health professionals are invited, par- 
ticularly administrative and technical laboratory 
personnel. Registration fee is $20 per day. 

Further information and registration forms 
may be obtained from Junemarie Bowling, 
MT( ASCPl, Conference Chairperson, Hygeia 
Facilities, Box 400, Oceana 24870. Telephone 
(304) 682-6246 (6247). 


Membership Amendments 
Set For House Vote 

Up for final action at the first session of the 
State Medical Association’s House of Delegates 
August 25 at the Greenbrier will be constitution 
and bylaws amendments to make residents in 
their first year of approved training eligible for 
Association membership. 

Under current state law, those first-year resi- 
dents are not eligible for licensure (they work 
under an educational training permit issued by 
the West Virginia Board of Medicine), and thus 
also are not eligible for Association membership 
pending licensure. 

Here is the language of the proposed consti- 
tution and bylaws changes: 


AMENDMENTS TO THE CONSTITUTION 

( Approved by the Committee on Constitu- 
tion and By-Laws, Executive Committee and 
the Council, August 25-26, introduced into 
House of Delegates August 26, 1982, and 
subject to action by the House August 25, 
1983.) 

Sec. 1. This Association shall consist of active, 
retired, honorary, resident and student members. 

Sec. 2. Members. Membership in the As- 
sociation shall be limited to doctors of medicine 
licensed to practice in West Virginia who are 
members of a component medical society of the 
West Virginia State Medical Association; resi- 
dents who are licensed to practice medicine in 
W est Virginia, or who are serving in internship I 
residency training programs approved by the 
West Virginia Board of Medicine prior to meet- 
ing requirements for licensure; and students en- 
rolled in accredited schools of medicine in West 
Virginia granting Doctor of Medicine degrees. 


Sec. 6. Resident members shall be those 
persons who are licensed to practice medicine in 
West Virginia, or who are serving in internship! 
residency training programs approved by the 
West Virginia Board of Medicine prior to meet- 
ing requirements for licensure, and ivho are 
qualified for membership under the By-Laws of 
this Association. 

ARTICLE XIV.— AMENDMENTS 

Sec. 1. The House of Delegates may amend 
any article of this Constitution by a two-thirds 
vote of the delegates present at any annual ses- 
sion, provided that such amendment shall have 
been presented in open meeting at the previous 
annual session, and that it shall have been 
published twice during the year in THE WEST 
VIRGINIA MEDICAL JOURNAL, or sent 
officially to each component society, and resi- 
dent and student members whose names are 
listed on the official roster of the Association at 


Review A Book 


Phe following books have been received by the 
Headquarters Office of the State Medical Associa- 
tion. Medical readers interested in reviewing any 
of these volumes should address their requests to 
Editor, The West Virginia Medical Journal, Post 
Office Box 1031, Charleston 25324. We shall be 
happy to send the books to you, and you may 
keep them for your personal libraries after sub- 
mitting to The Journal a review for publication. 

Basic and Clinical Pharmacology, by Bertram 
G. Katzung, M. D., Ph.D. 815 pages. Price 
$23.50. Lange Medical Publications, Los Altos, 
California 94022. 1982. 

Current Medical Diagnosis and Treatment, 
1983, edited by Marcus A. Krupp, M. D.; and 
Milton J. Chatton, M. D. 1130 pages. Price $24. 
Lange Medical Publications, Los Altos, Cali- 
fornia 94022. 1983. 

General Ophthalmology, 10th Edition, by 
Daniel Vaughan, M. D.; and Taylor Asbury, 
M. D. 407 pages. Price $17. Lange Medical 
Publications, Los Altos, California 94022. 
1983. 

Neuroanatomy. An Atlas of Structures, Sec- 
tions, and Systems, by Duane E. Haines, Ph.D., 
Professor of Anatomy, West Virginia University 
School of Medicine, Morgantown. 212 pages. 
Price $19.50. Urban & Schwarzenberg Medical 
Publishers, 7 East Redwood Street, Baltimore, 
Maryland 21202. 1983. 


136 


The West Virginia Medical Journal 



least two months before the meeting at which 
final action is to be taken. 

( Words in italics indicate new portion to be 
added or a change in old verbage. The purpose 
of the amendments is to provide eligibility for 
State Association membership for interns/resi- 
dents in their first year of approved training, 
before they can be licensed under state law.) 

AMENDMENT TO THE BY-LAWS 

(Approved by the Committee on Constitu- 
tion and By-Laws, Executive Committee and 
the Council. August 25-26, also introduced 
in House August 26, 1982. and now await- 
ing action by the House August 25, 1983.) 

Sec. 1. The name of a physician on the 
properly certified roster of members of a com- 
ponent society shall be prima facie evidence of 
membership in this Association, provided he has 
paid local and state dues and any current as- 
sessment, and provided further that he is licensed 
to practice medicine in West Virginia. The 
membership also shall include, upon payment of 
state dues and any current assessment; a resident 
licensed to practice medicine in West Virginia, 
or who is serving in an internship residency 
training program approved by the West Virginia 
Board of Medicine prior to meeting requirements 
for licensure; and a student enrolled and working 
toward a Doctor of Medicine degree, in any 
accredited school of medicine in West Virginia: 
provided, further, that the academic status of 


each medical student applicant for membership 
shall be certified by the dean of his medical 
school. 

Sec. 4. Each member in attendance at an an- 
nual session shall register and indicate the com- 
ponent society, or Resident or Medical Student 
Section, of which he is a member. When his 
right to membership has been verified by 
reference to the roster of his society, Resident 
or Medical Student Section, he shall receive a 
badge which shall be evidence of his right to all 
privileges of membership at that session. No 
member shall take part in any of the proceedings 
of an annual session until he has complied with 
the provisions of this Section. 

(Note: New language is set in italics. The 

amendment would make an intern /resident in 
his first year of approved training, and prior to 
licensure under state law, eligible for State Medi- 
cal Association membership and thus provide for 
implementation of the preceding constitutional 
amendment. ) 


ACP Fellow 

Dr. Thomas W. Mou of Charleston was named 
a Fellow of the American College of Physicians 
at the organization’s recent annual meeting in 
San Francisco. Doctor Mou is Dean of the 
Charleston Division, West Virginia Medical Cen- 
ter, and former Acting Vice Chancellor for the 
West Virginia Board of Regents (1979-82). 



Dr. Earl L. Fisher of Gassaway, whose career spans nearly 50 years, received the “Mister Doc” Award, 
the highest honor bestowed by the West Virginia Chapter, American Academy of Family Physicians, during 
the Academy’s annual scientific assembly held recently in Morgantown. In the left photo. Doctor Fisher and 
some of his family are shown following presentation of the award. In the right photo are new AAFP officers 
for 1983-84 who were installed during the meeting. They are, from left, Drs. William H. Harriman, Jr., Terra 
Alta, President Elect; Joseph B. Reed, Buckhannon, Vice President; Michael J. Lewis, St. Marys, Secretary; 
Robert D. Hess, Clarksburg, Chairman of the Board; A. Paul Brooks, Jr., Parkersburg, President; John L. 
Fullmer, Morgantown, Alternate Delegate, AAFP; and L. Dale Simmons, Clarksburg, Delegate, AAFP. Not 
shown is Dr. John V. Merrifield, Charleston, Treasurer. 


' 3 | 


June, 1983, Vol. 79, No. 6 


137 


aHVUS >1 


AMA House of Delegates 
Meets June 19-23 

The annual meeting of the American Medical 
Association’s House of Delegates will be held 
June 19-23 in Chicago at the Marriott Hotel. 

The West Virginia State Medical Association’s 
two Delegates to the AMA House of Delegates 
are Drs. Frank J. Holroyd of Princeton and 



Frank J. Holroyd, M. D. Harry S. Weeks, Jr., M. D 


Harry S. Weeks, Jr., of Wheeling, with Drs. 
Jack Leckie of Huntington and Joseph A. Smith 
of Dunbar as Alternate Delegates. 

The House of Delegates is composed of repre- 
sentatives from state medical associations, na- 
tional medical specialty societies, resident physi- 
cians, medical students, medical schools and 
other medical groups. 

Dr. William Y. Rial of Swarthmore, Pennsyl- 
vania, is President of the AMA. President Elect 
is Frank J. Jirka, M. D., of Barrington Hills. 
Illinois, who will assume the presidency during 
the meeting. 


New Feature 

The program for the State Association’s An- 
nual Meeting August 25-27 at The Greenbrier 
will have a new feature. Being arranged for 
Saturday night is a dinner open to the member- 
ship to honor the new Association and Auxiliary 
officers, and recognize those who have served in 
1982-83. 

T1 ie black-tie affair s guests will include visit- 
ing Presidents from other states and their 
spouses, and from the American Medical Asso- 
ciation. Ticket and other information will he 
forthcoming in July and August issues of The 
Journal. The Auxiliary’s current plans are to 
delete from its activities a Friday night social 
affair it has held for some time, and to partici- 
pate in the August 27 dinner. 


Medical Meetings 


June 5-9 — Am. Society of Colon & Rectal Surgeons, 
Boston. 

June 7-10 — Society of Nuclear Medicine, St. Louis. 

June 16-17 — Summer Management/Laboratory Con- 
ference (Hygeia Facilities and WVU Medical 
Center, Charleston Div.), Beckley. 

June 17-18 — Society for Vascular Surgery, San 
Francisco. 

June 19-23- Annual Meeting of AMA House, Chi- 
cago. 


June 22-25 — Am. College of Surgeons, Eastsound, 
WA. 

June 23-26 — Am. Medical Women’s Assoc., Minne- 
apolis. 

Aug. 25-27 — 116th Annual Meeting, W. Va. State 
Medical Assn., White Sulphur Springs. 

Sept. 29-Oet. 1 — Am. Assoc, for the Surgery of 
Trauma. 

Sept. 29-Oct. 2 — Am. Society of Internal Medicine, 
San Francisco. 

Oct. 2-5 — Am. Neurological Assoc., New Orleans. 

Oct. 5-8 — Am. Thyroid Assoc., New Orleans. 

Oct. 16-21 — Am. College of Surgeons, Atlanta. 

Oct. 22-27 — Am. Academy of Pediatrics, San Fran- 
cisco. 

Oct. 23-27 — Am. College of Chest Physicians, 
Chicago. 

Oct. 23-29 — Am. College of Gastroenterology, Los 
Angeles. 

Oct. 24-27— Am. College of Emergency Physicians, 
Atlanta. 

Nov. 6-9 — Scientific Assembly, Southern Medical 
Assoc., Baltimore. 

Nov. 30-Dec. 1 — Am. College of Chemosurgery, 
Chicago. 

1984 

Jan. 27-29 — 17th Mid-Winter Clinical Conference, 
Charleston. 


March 17 — Annual Meeting, W. Va. Affiliate, 
American Diabetes Assoc., Wheeling. 


138 


The West Virginia Medical Journal 



WHY BMW CHOSE 

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WVU Medical Center 
-News- 


Compiled from material furnished by the Medical Center 
News Service, Morgantown, W. Va. 


Toxic Shock Still Problem 
As Publicity Dwindles 

Toxic shock syndrome continues to be a 
medical problem despite removal from the 
market of high absorbency tampons believed to 
predispose menstruating women to infection. 

In fact, 10 per cent of all cases diagnosed as 
toxic shock syndrome have no direct relation to 
menstruation, according to Larry G. Reimer, 
M. D., Director of the Clinical Microbiology 
Laboratory. 

Doctor Reimer, who also is Assistant Professor 
of Medicine and Pathology, said public aware- 
ness probably bad resulted in patients seeking 
medical help earlier and a lowering of the 
mortality rate. 

“But on the other hand, a lot of publicity 
about toxic shock syndrome has now died down,” 
he said. “Some physicians may have reached 
a point where they think it’s not a problem any- 
more. 

Not Always Recognized 

“That’s really not the case. Of the three 
patients treated at the Medical Center since the 
first of the year, one had been seen by two or 
three physicians before diagnosis. So it’s not 
something that everybody immediately recog- 
nizes even now. 

“Staphylococcus aureus is a commonly occur- 
ring bacteria,” he explained. “Anywhere from 
20 to 40 per cent of all women will have it in 
vaginal cultures. Just having the organism there 
doesn’t say anything about toxic shock.” 

But a large growth of the microorganism com- 
bined with typical symptoms would confirm the 
diagnosis after other diseases such as scarlet 
fever, scalded skin syndrome. Rocky Mountain 
spotted fever or measles had been ruled out. 

Symptoms are a fever of more than 101 F., 
a systolic blood pressure reading of less than 90, 
a rash and multi-system involvement manifested 



by mental confusion, nausea and vomiting, 
diarrhea, kidney or liver impairment, anemia, or 
decreased blood clotting elements. 

“If we get a vaginal culture that grows a large 
amount of staph aureus, we always call the 
physician because the laboratory slips don’t 
always tell us what diagnosis is being con- 
sidered,” Doctor Reimer said. 

“If we know the clinical diagnosis of toxic 
shock syndrome is suspected, we specifically look 
for staph aureus.” 

The illness is caused by a toxin secreted by the 
bacteria, Doctor Reimer said. Those cases not 
associated with menstruation occur when the 
microorganism enters the body through surgical 
wounds, skin lesions or following childbirth. In 
the case of surgical wounds, there is usually no 
local inflammation, pain or tenderness. 


Female Donors’ Blood Depletion 
Faster, Says Researcher 

A WVU Medical Center researcher against 
equal rights for women? 

No, but S. N. Jagannathan, Ph.D., is against 
a U. S. Food and Drug Administration rule 
which does not discriminate between men and 
women when it comes to frequency of repeat 
blood donations. 

Doctor Jagannathan recently told the Federa- 
tion of American Societies for Experimental 
Biology his study indicates that maximum giving 
can deplete the body’s iron storage status and 
that women are much more at risk than men. 

Doctor Jagannathan, Associate Professor of 
Pathology and Biochemistry, and graduate 
student Cary Stoner studied 328 blood donors. 

Current FDA rules, approved by the American 
Association of Blood Banks, let male and female 
donors give a unit of blood every eight weeks. 
Doctor Jagannathan said his investigation shows 
that at the present eight-week limit, donors’ iron 
stores do not get replenished from the typical 
American diet alone. 


xvi 


The West Virginia Medical Journal 


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ANESTHESIOLOGY: 

Y. H. Chung, M. D. 

COMMUNITY MEDICINE: 

R. C. Gow, M. D. 
(Thomas Clinic) 

S. O. Chung, M. D. 

M. C. Rosenberg, D. O. 
(Helvetia Clinic) 

EMERGENCY MEDICINE: 

R. H. Plummer, D. O. 

A. M. Fuller, M. D. 

F. A. Khan, M. D. 

D. J. Lloyd, M. D. 

FAMILY PRACTICE: 

L. H. Valliant, M. D. 

C. S. High, M. D. 


INTERNAL MEDICINE: 
Gastroenterology: 

S. S. Masilamani, M. D. 

Allergy & Rheumatology: 

J. B Magee, M. D. 

Cardiology: 

H. L. Jellinek, M. D. 

R. B. Garrett, M. D. 

Metabolic & Endocrine Diseases: 
F. Becerra, M. D. 

Pulmonary Diseases: 

J. C. Arnett, Jr., M. D. 

OBSTETRICS & GYNECOLOGY: 

H. H. Cook, Jr., M. D. 

J. F. de Courten, M. D. 

J. J. Rizzo, M. D. 

M. W. Strider, M. D. 

OPHTHALMOLOGY: 

J. N. Black, M. D. 

ORTHOPAEDIC SURGERY: 

J. G. Gomez, M. D. 


OTOLARYNGOLOGY 
(Facial Plastic and 
Reconstructive Surgery): 

J. A. Wolfe, M. D. 

PATHOLOGY: 

M. M. Stump, M. D. 
PEDIATRICS: 

Y. J. Kwon, M. D. 

R. J. Haas, M. D. 

PSYCHIATRY: 

R. W. O'Donnell, M. D. 

RADIOLOGY: 

F. H. Abdalla, M. D. 

H. Y. Mang, M. D. 

C. P. O'Sullivan, M. D. 

SURGERY: 

General, Thoracic & Vascular: 

J. A. Noronha, M. D. 

W. B. Blum, M. D. 

B. R. Blackburn, M. D. 

R. A. Rose, M. D. 

UROLOGY: 

D. T. Chua, M. D. 


June, 1983, Vol. 79, No. 6 


XVII 


Third-Party News, Views 
and Program Concerns 



Welfare Clarifies Medicaid 
Office Visit Coverage 

The West Virginia Department of Welfare is 
providing clarification for the state’s physicians 
relative to coverage of office visits under the 
Medicaid Program. Current experience is re- 
flecting some apparent misunderstanding of such 
coverage. 

The program coverage provides reimburse- 
ment for one medical service per day; i.e., Medi- 
caid covers one “visit procedure” daily. Further 
amplification of this provision will be provided 
in notices to individual doctors. 

Because of processing program errors, pay- 
ment has been made in tbe past for a combina- 
tion of daily visits. Now, as tbe erroneous pay- 
ments might be identified, physicians will be 
notified and steps taken to adjust tbe claims. 

In the future, the Department explained, such 
combination claims will bring a denial for pay- 
ment. A remittance statement will read, “This 
claim conflicts with a previously submitted 
claim. Tbe conflicting claim (tbe paid claim) 
also will be listed on the remittance voucher. 

The Department said some examples of con- 
flicting service situations have been identified 
as an office visit and a home visit in one day; 
office visit and nursing home visit; office visit 
and emergency room visit; emergency room visit 
and hospital visit; office visit and hospital visit; 
office visit and consultation; nursing home visit 
and office visit, and surgery and another type 
of visit. 


Reagan Applauds Free Care 
For U.S. Unemployed 

President Reagan has applauded voluntary 
efforts by state, county and national specialty 
societies to provide free and low-cost medical 
care to tbe nation’s unemployed. In a recent 
White House meeting commemorating National 
Volunteer Week, medical society representatives 
told the President about their programs for 

xviii 


“newly needy” patients who are ineligible for 
Medicare and Medicaid, have no health in- 
surance. or are otherwise unable to pay. Tbe 
programs included free clinics, health screening, 
and no-cost or low-cost medical and surgical 
services. 

AMA President William Y. Rial. M. D., pre- 
sented Reagan with a report on 23 health pro- 
grams for the unemployed. Reagan told Doctor 
Rial, “You know how strongly I believe in the 
power of private sector initiatives — almost as 
much as some of those old home remedies that 
my mother used to use. One thing is for sure, 
I know that local efforts such as those I’ve just 
heard about can help tremendously in curing tbe 
ills of our country.” 


New Ways To Protect Newborns 
With Handicap Explored 

American Medical Association representatives 
met recently with U. S. Department of Health 
and Human Services officials to discuss alterna- 
tive approaches for implementing the White 
House mandate to protect severely handicapped 
newborns. Earlier, U. S. District Court Judge 
Gerhard A. Gesell had struck down new federal 
regulations that required hospitals to post notices 
in delivery rooms and nurseries publicizing a 
24-hour, toll-free hot line to be used in cases of 
suspected neglect. 

Following Judge Gesell’s ruling, AMA staff 
and representatives from tbe American Academy 
of Pediatrics, American College of Obstetrics 
and Gynecology. Federation of American Hos- 
pitals, American Hospital Association, and tbe 
National Association of Children’s Hospitals met 
for two hours with John Svahn, Undersecretary 
of Health and Human Services, and C. Everett 
koop. M. D.. Surgeon General of the U. S. 
Public Health Service. The medical organiza- 
tions were unanimous in their opposition to the 
rulemaking, and advised HHS to enlist the 
cooperation of the professional community. 


The West Virginia Medical Journal 



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June. 1983, Vol. 79, No. 6 


XIX 



Obituaries 


WILLIAM E. ANDERSON, M. D. 

Dr. William E. Anderson of Cumberland. 
Maryland, formerly of Morgantown, died on 
April 4 in Cumberland. A gastroenterologist, be 
was 55. 

Doctor Anderson was a member of the faculty 
of the West Virginia University School of Medi- 
cine from 1960 to 1980. when be resigned to 
begin group practice in Cumberland. He was 
head of the Gastroenterology Section at WVU. 

A native of Mankato, Minnesota, Doctor 
Anderson was graduated from Gustavus Adolphus 
College in St. Peter. Minnesota, and received bis 
M. D. degree in 1954 from the University of 
Minnesota. 

He was a former member of the Monongalia 
County Medical Society and the West Virginia 
State Medical Association. 

Survivors include the widow: a son, Evan 
Anderson, at home; the stepmother, Mrs. Evan 
Anderson of San Francisco, and a brother. Dr. 
Richard Anderson of Eugene, Oregon. 


SPENCER L. BIVENS, M. D. 

Dr. Spencer L. Bivens, retired Charleston 
surgeon, died on May 3 in a nursing home there. 
He was 82. 

A veteran of World War II, Doctor Bivens 
was President of the Kanawha Medical Society 
in 1947. 

He was born in Meadow Bluff f Greenbrier 
County ) . 

Doctor Bivens received his M. D. degree in 
1928 from Emory University, and completed 
postgraduate work at Maryland General Hospital 
in Baltimore and Charleston General Hospital. 

He was an honorary member of the Kanawha 
Medical Society, West Virginia State Medical 
Association and American Medical Association. 

Survivors include a son. Dr. Spencer E. Bivens, 
Jr., of Charleston: a daughter, Mrs. Sara Dawkins 
of Marietta. Georgia; and a brother. Carl Bivens 
of Alderson. 

* # * 

RICHARD W. WINGFIELD, M. I). 

Word has been received by The Journal of the 
death of Dr. Richard W. Wingfield on January 
7 in Keller, Virginia. He was 57. 


A native of Elkins, Doctor Wingfield was 
graduated from West Virginia University, and 
received his M. D. degree in 1952 from the 
Medical College of Virginia. 

Survivors include the widow and three sons, 
all of Keller. 

* * * 


JAMES E. WOTRING, M. D. 

Dr. J ames E. Wotring of Fairview ( Marion 
County), retired family physician, died on 
March 5 in a Morgantown hospital. He was 61. 

Doctor Wotring was a former member and 
President ( 1963-64 ) of the Marion County 
Medical Society, and a former member of the 
West Virginia State Medical Association. 

Survivors include the widow; two daughters. 
Mrs. Ronnie Tucker of Morgantown and Mrs. 
Paul Cams of Latrobe, Pennsylvania: four 

brothers. Ernest H. Wotring of Marshall, Texas; 
Daniel J. Wotring. Jr., of Clinton, Maryland: 
Donald R. Wotring of Artesina, New Mexico, 
and William R. Wotring of Morgantown; and 
three sisters, Mary Shafer of Marlinton, Eleanor 
Wotring of Morgantown and Mrs. Edward 
Warsinsky of Morgantown. 


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xx 


The West Virginia Medical Journal 



County Societies 


McDowell 

The McDowell County Medical Society met on 
April 13 in Welch at Stevens Clinic Hospital. 

Dr. John Goldman. Assistant Professor of 
Medicine, Rheumatology and Immunology, at 
Emory University in Atlanta, was guest speaker. 
His subject was the management of rheumatic 
diseases. He stressed the importance of a physi- 
cal therapy program for the rheumatic patient. 

The Society voted to make a donation equal 
to the 1982 amount to Camp Kno Koma. — John 
S. Cook. M. D., Secretary. 

# # « 

TYGART’S VALLEY 

Dr. Charles Howell, a psychologist from the 
Appalachian Mental Health Center in Buck- 
hannon, presented a workshop on “Instant 
Aging ' for the meeting of the Tygart’s Valley 
Medical Society on April 21. 

Held at Broaddus Hospital in Philippi, the 
purpose of the workshop was to enable volunteer 


participants from the audience to experience and 
understand the age-related medical complaints 
of the elderly, particularly the low-grade chronic 
losses in their daily routine. 

The volunteer subjects were “instantly aged” 
by plugging their ears with cotton halls, wearing 
rubber gloves and taping the joints of the hands, 
wearing goggles smeared with mineral oil. etc. 

-Halherto G. Cruz, M. D., Secretary. 

# # # 

FAYETTE 

The Fayette County Medical Society held a 
combined meeting with its Auxiliary on April 
6 at the White Oak Country Club in Oak Hill. 

The guest speaker was the Honorable Judge 
Robert Abbot, who discussed criminal law, and 
compared the English and American judicial 
systems. — Serafino S. Maduedoc, Jr., M. D., 
Secretary-T reasurer. 


EQUIPMENT WANTED 

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Send responses to Joseph I. Golden, M. D., 
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OPHTHALMOLOGY 

Robert K. Modlin, M. D. 
Helen R. Perez, M. D. 

Robert K. Scott, II, M. D. 

Thomas F. Mann, M. D. 

PEDIATRICS 

Anthony C. Dougherty, M. D. 

Williams S. Dukart, M. D. 

SURGERY 

Janice Centa, P. A., M. S. 

General & Vascular 

RADIOLOGY 

H. P. Dinsmore, M. D. 

Charles Weinstein, M. D. 

General & Thoracic 

B. L. Plybon, M. D. 

PSYCHOLOGY 

ORTHOPEDIC SURGERY 

Connie Bradley-Mann, Ph. D. 

Conrad D. Tamea, Jr., M. D. 

ANCILLARY SERVICES 

James W. Banks, M. D. 

Physical Therapy 

FAMILY GENERAL PRACTICE 

Tom Moore, R. T. 

Joseph E. Shaver, M. D. 

Wood McCue, R. T. 

E. T. Cobb, M. D. 

Respiratory Therapy 

OBSTETRICS/GYNECOLOGY 

James D. Creasman, R.R.T. 

James L. Pfeiff, M. D. 

Audiology 

Robert L. Wheeler, M. D. 

Gary M. Vandevander, M.S. 

EAR, NOSE & THROAT 

ADMINISTRATION 

Amir A. Alidina, M. D. 

Sandra W. Ayers, Business Manager 


June, 1983, Vol. 79, No. 6 


XXI 



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The West Virginia Hedicai Journal 


Vol. 79, No. 7 July, 1983 

Value And Limitations Of The Noninvasive Laboratory: 
Experience With Over 5,000 Patients 


ALI F. ABURAHMA, M. D. 

Director, Noninvasive Vascular Laboratory, Charleston 
Area Medical Center, Charleston, West Virginia; and 
Clinical Associate Professor in Surgery, West Virginia 
University Medical Center, Charleston Division. 

LINDA OSBORNE. L.P.N. 

Vascular Technologist, Charleston 


Today , the physician is assisted in the manage- 
ment of vascular diseases by the various non- 
invasive diagnostic modalities offered by the 
vascular laboratory. The idea of having a 
vascular laboratory has become popular in most 
of the major medical centers in the last decade. 
In 1978, a vascular laboratory was established 
at the Charleston Area Medical Center to provide 
diagnostic testing for carotid artery disease or 
cerebral ischemia, arterial occlusive disease of 
lower and upper extremities, and deep vein 
thrombosis of the extremities. 

The purpose of this article is to define the 
value of the noninvasive vascular laboratory in 
the diagnosis of vascular disorders, to describe 
some of its occasional limitations, and to present 
the results of over 5,000 patients tested in the 
laboratory from August, 1978, through March, 
1982. Emphasis is placed on tests available in 
our laboratory. 

Carotid Artery Disease 

Various noninvasive diagnostic modalities 
have been described for the diagnosis of 
carotid artery stenosis; e.g., oculoplethysmo- 
graphy (OPG); Doppler ultrasound (continuous 
wave); ophthalmodynamometry; thermography; 
pulsed Doppler arteriogram; B-image scanning; 
real-time, B-image scanning; spectrum sound 


analysis; new duplex scanning; color-coded 
Doppler ultrasound (echo-flow), and carotid 
phonoangiography (CPA). Table 1 shows what 
is available in the laboratory. 

There are essentially two types of oculople- 
thysmography (OPG) devices: 

Ocular Pulse Timing OPG ( Kartchner-OPG 
and Zira OPG). This test is based on compari- 
son of the time of arrival of the arterial pulse at 
each eye. When no disease is present, both 
pulses arrive simultaneously. Pulse delay in one 
eye usually signifies a narrowing or blockage of 
the internal carotid artery on the affected side; 
e.g., left internal carotid artery stenosis produces 
a delayed pulse to the left eye and thus a visible 
delay in the left ocular wave tracing (Figure la 

& b). 

Ophthalmic Artery Pressure OPG ( Pneu- 
mooculoplethysmography ) iOPG-Gee) . This 
test is based on comparison of the two ophthal- 
mic systolic pressures with each other and with 
the supine brachial systolic pressure. Using 
certain guidelines outlined by Doctor Gee in his 

TABLE 1 

What Is Available in the CAMC Vascular Laboratory 
For the Noninvasive Diagnosis of 
Carotid Artery Stenosis 

1. Oculoplethysmography (OPG/Zira) 

2. Oculoplethysmography (OPG/Gee)® 

3. Carotid Phonoangiography (CPA) 

4. Carotid arterial Doppler ultrasound 

5. Real-time B-image carotid scanner® 

°The tests we recommend currently 


July, 1983, Vol. 79, No. 7 


139 


original work on this machine, 11 the diagnosis of 
significant carotid stenosis can be made I Figure 
lc). 



Figure la. An oculoplethysmography (OPG) of a 
patient with left carotid artery stenosis. 



Figure lb. Carotid arteriogram showing the left 
carotid stenosis. 



Figure lc. OPG-Gee technique. 


Clinical Experience 

Using pulse timing OPG, 161 patients (309 
carotid arteries I from 2,300 OPGs done at 
Charleston Division, West Virginia University 
Medical Center, from September, 1978, to 
September, 1981, were studied in comparison 
with the carotid arteriograms. The age range 
was 36 to 78 years. 

All the angiograms were reviewed by a 
radiologist and one or two vascular surgeons. For 
practical purposes, the radiological findings were 
classified as follows: a normal carotid artery, 

mild disease, less than 40-per cent stenosis; sig- 
nificant stenosis, > 40-per cent up to 99-per cent 
stenosis; and total occlusion. The results are 
shown in Table 2. 

We concluded that OPG is valuable in the 
diagnosis of normal carotid arteries, unilateral 
significant carotid stenosis, significant carotid 
stenosis on one side and mild stenosis on the 
other side, and unilateral complete carotid 
occlusion. We also concluded that OPG has 
limited value (around 56 per cent) in the diag- 
nosis of bilateral significant carotid stenosis. 

Of 550 patients using OPG/Gee, 100 had 
arteriograms. Results are shown in Table 3. We 
concluded that OPG/Gee is more valuable in 
the diagnosis of both unilateral and bilateral 
significant carotid stenosis ( 90.3 per cent and 
90.4 per cent). 

TABLE 2 

Correlation of Pulse Timing OPG With Arteriogram 


Bilateral Carotid Disease 


r o 5 


s 8 
: a 
± .52 

l itr'-w © 

* s 2 8 
i.Sf « £ 

3 GoO C/5 


8 c- 


*2 J’C 
£ 

© © c 


OPG/Zira 

101 

61 

32 

15 47 

13 

Arteriogram 

92 

53 

40 

27 67 

12 

Accuracy 

91% 

87% 

80% 

56% 70% 

92% 



TABLE 3 



Correlation of OPG/Gee With Arteriogram 


Normal 

Unilateral 

significant 

stenosis 


Bilateral 

significant 

stenosis 

Total 

Arteriogram 

48 

31 


21 

100 

OPG/Gee 

45 

28 


19 

92 

Accuracy 

94% 

90.3% 


90.4% 

92% 


140 


Tiif. West Virginia Medical Journal 


Discussion 

The value of the OPG has been well estab- 
lished in the diagnosis of significant carotid 
artery stenosis. 2,5,n ’ 12,13 ’ 14 It is to be noted that 
neither the OPG nor any indirect method has 
been of value in detecting any hemodynamically 
non-significant carotid stenosis of less than 40 
per cent. Those nonsignificant stenoses can be 
associated with ulcers which have the ability to 
cause embolization (transient ischemic attack). 

Many advantages of OPG give evidence of its 
practicality. OPG is administered quickly and in- 
expensively. While being well-tolerated by the 
patient, it allows for identification of significant 
carotid stenotic lesions. Certain limitations, how- 
ever, must be noted. The accuracy is poor in 
nonhemodynamically significant stenosis of less 
than 40- or 50-per cent stenosis. It cannot 
identify an ulcerative plaque if not associated 
with significant stenosis. Sometimes, differentia- 
tion between severe stenosis and complete occlu- 
sion cannot be determined. Some OPGs are 
limited in bilateral significant stenosis. 

B-Mode Image Carotid Scanning 
(and Real-Time, B-Image Scanning) 

Now available are instruments producing gray- 
scale images of high resolution and accurately 
identifying atherosclerotic disease at or near the 
carotid arterial bifurcation. Real-time presenta- 
tion of these images using a hand-held trans- 
ducer provides an immediate visualization of the 
lesion and reduces problems associated with 
locating the artery and positioning the patient. 
Videotapes of the images can be stored for 
reevaluation or comparison with previous or sub- 
sequent scan data (Figure 2a through e). These 



Figure 2a. The real-time-B-mode-carotid image 
scanner. 


direct methods, particularly the real-time, B- 
image scanner, visualize the carotid artery 
directly and detect even mild stenotic lesions as 
compared with the OPG. 

In our laboratory, we presently combine both 
OPG/Gee and the real-time carotid image scan- 
ner. 

The recommended protocol for the diagnosis 
of carotid artery disease is shown in Figure 3. 

Arterial Occlusive Disease 
of Lower Extremities 

Testing for arterial occlusive disease of the 
lower extremities employs various noninvasive 
modalities which have been described in the 
diagnosis of peripheral vascular occlusive diseases 
iPVOD); e.g., pulse volume detectors: thermo- 
graphy; Doppler ultrasound (continuous wave); 
plethysmography: pulsed Doppler arteriography; 



Figure 2b. Real-time, B-image-carotid scan show- 
ing normal common carotid (CC), internal carotid 
(IC) and external carotid (EC). 



Figure 2c. Real-time, B-image scan showing mild 
stenosis at the carotid bifurcation. 


r* 



July, 1983, Vol. 79, No. 7 


141 



B-image scanning; real-time, B-image scanning: 
new duplex scanner, and spectrum sound 

analysis. 

The most common method being used in this 
country is the Doppler ultrasound instrumenta- 
tion (continuous wave). This method is em- 
ployed in our vascular laboratory. The value of 
the Doppler ultrasound in the diagnosis of 
peripheral vascular occlusive disease has been 
well documented. 1,3, 4,6,16,17 

Clinical Material, Methods and Results 

Between August, 1978, and March. 1982, 
1,080 patients had arterial leg Doppler studies 



Figure 2d. Real-time, B-image scan showing com- 
plete occlusion of the internal carotid artery (CC: 
common carotid, EC: external carotid, and IJV: 
internal jugular vein). 



Figure 2e. The same patient (2d) with complete 
occlusion of the internal carotid artery (arteriogram). 


(ALD I with or without exercise. Table 4 shows 
the indications for these tests. We selected the 
first 150 patients (300 limbs) who had both 
ALD and arteriograms for this study. 

Each limb was studied in four arterial seg- 
ments: 300 iliofemoral, 300 femoral, 282 

popliteal, and 275 trifurcation segments. 
Eighteen popliteal and 25 trifurcation segments 
were excluded because of the lack of angio- 
graphic visualization (not enough dye). 

Every arterial Doppler examination consisted 
of an evaluation of segmental leg pressures, 
analysis of the leg pressures in correlation with 
the arm pressures (ankle /arm index), arterial 
wave tracing, and, if indicated, an exercise test. 
The arm systolic pressure and the segmental leg 
pressures were recorded from blood pressure 

TABLE 4 

Indications for Arterial Doppler Examination 


1. Calf pain while walking. 

2. Leg pain at rest. 

3. Skin changes suggestive of arterial insufficiency. 

4. Nonhealing ulcers. 

5. Previous vascular reconstructive procedures. 


TABLE 5 

Segmental Pressure and Ankle/Arm Index in a 
Patient With Occlusion of the Left Superficial 
Femoral Artery 


Resting 

Right 
( Normal ) 

Left 

( Abnormal ) 

Arm 

150 

160 

High thigh 

200 

206 

Above knee 

184 

150 

Below knee 

168 

144 

Ankle (posterior tibial) 

150 

128 

Ankle (dorsalis pedis) 

150 

128 

Ankle/arm index 

(150/150)1.0 

(128/160). 80 

^-Positive 

OPC/Cee^^^ 

Negative 

► Angiogra 

» No Symptoms (No 

111 

TIA)— ► ( )bserve 


1 

Negative 

with 

TIA 


Real-Time Carotid Image Scanner 



No more symptoms Frequent symptoms 

* I 

Observe & Follow-up Angiogram ? 


Figure 3. Recommended protocol for the diagnosis 
of carotid artery disease. 


142 


The West Virginia Medical Journal 


cuffs placed at the high area of the thigh, above 
the knee, below the knee, and at the ankle 
I Figure 4 ) . Resting segmental systolic pressures 
were taken at each level, and the highest reading 
of the posterior tibial and dorsalis pedis systolic 
pressures was used as the ankle pressure. The 
ankle/arm index was then calculated. The pres- 
ence of greater than 30 mm. Hg gradient be- 
tween any adjacent level in the leg indicates sig- 
nificant occlusive disease (Table 5). 

TABLE 6 

Segmental Pressure Reading and Ankle/Arm Index 
After Exercise in a Patient With Severe Peripheral 
Vascular Occlusive Disease of the Left Leg 


After Exercise 

Right Ankle 
( Normal ) 

Left Ankle 
( Abnormal ) 

Arm 

1 minute 

186 

50 

180 

2 minutes 

186 

58 

180 

4 minutes 

180 

60 

176 

6 minutes 

180 

70 

170 

10 minutes 

166 

78 

160 

15 minutes 

170 

90 

162 

20 minutes 

170 

130 

162 

Ankle/arm index 

(186/180)1.03 

(50/180)0.27 



Normal Abnormal 

Ankle/Arm Index Ankle/Arm Index 



f 




Figure 4. Arterial leg Doppler study showing the 
segmental Doppler pressures. Note that this study 
shows significant stenosis of the left superficial 
femoral artery. 


Minimal and/or moderate disease is some- 
times not manifested without exercise, so exer- 
cise tests are done if indicated. The ankle/arm 
pressures are then taken after exercise and re- 
corded at timed intervals until they return to 
pre-exercise levels (Table 6). The blood flow is 
indirectly assessed by determining the velocity 
in the form of analogue wave tracings. Normally, 
an analogue wave tracing has a sharp systolic 
and one or more diastolic components. Abnormal 
tracings caused by atherosclerotic disease may 
show a lack of diastolic components and/or 
diminished systolic components (Figure 5). 

The results are shown in Table 7. We con- 
cluded that this method is very helpful in the 
diagnosis of arterial occlusive disease of the 
lower extremities with 94-per cent accuracy. 

Deep Vein Thrombosis of Lower Extremities 

The fallibility of the clinical diagnosis of deep 
venous thrombosis (DVT) has led to a variety 

TABLE 7 


Correlation of Arterial Doppler Studies and 
Arteriograms (Total Segments Studied) 


Total segments 
studied hy 

Segments Arterial Doppler 

Findings 
confirmed hy 
Arteriograms 

% Accuracy 

Iliofemoral 

300 

282 

93% 

Femoral 

300 

280 

95% 

Popliteal 

282 

262 

94% 

Trifurcation 

275 

262 

94% 

Total 

1,157 

1,086 

94% 


Normal Abnormal 



Figure 5. Analogue arterial wave tracing, normal 
right side and abnormal left side. 


of noninvasive diagnostic modalities like: Dop- 
pler ultrasound, impedance, air, mercury and 
strain gauge plethysmograph, 1-25 fibrinogen, 
and radionuclide phlebography. 

The strain gauge plethysmography (SPG), the 
impedance plethysmograph (IPG), and the 
Doppler venous ultrasound are probably the 
most common tests used in this country for the 
diagnosis of deep vein thrombosis (DVT). In 
our laboratory, we have been using the strain 
gauge plethysmography and sometimes 1-25 
fibrinogen leg scanning. 



Figure 6. The technique of the strain gauge 
plethysmography (SPG) for the diagnosis of deep 
vein thrombosis (DVT). 

C 


Tim* in ucondi 
undti tingant line 

T 0 



Figure 7. Nomograph for measurement of maxi- 
mum venous outflow in the diagnosis of deep vein 
thrombosis (DVT). 


Using strain gauge plethysmograph (Meda- 
Sonics), the patient lies in a supine position 
with the knee being tested flexed at 15 to 20 
degrees. The leg is elevated with support under 
the thigh and foot so that the calf is 20 to 25 
centimeters above the examination table. The 
strain gauge is positioned around the maximum 
girth of the calf. The gauge is connected to the 
plethysmograph, and a thigh pneumatic cuff is 
connected to an automatic cuff inflator (Figure 
6). The thigh cuff is inflated to 50 millimeters 
Hg for a period of two minutes and then quickly 
deflated. With the help of Nomagraph, the maxi- 
mum venous outflow (MVO) can be calculated 
(Figure 7). 

It is desirable to repeat the procedure at least 
one time. Results should be comparable. The 
procedure should be repeated until consistent 
results are obtained. 

Diagnostic criteria for calf outflows (MVO): 

41 ± 11 cc/min/100 cc tissue ( % min) — 
within normal limits. 

12 ± 8 cc/min/100 cc tissue (% min) — 
compatible with DVT. 

1-125 Fibrinogen Leg Scanning 

Radioactive fibrinogen assesses the activity of 
the thrombotic process. One hundred microcuries 
of 1-25 labeled human fibrinogen is injected 
intravenously. The circulating fibrinogen will 
become incorporated into sites of active 
thrombosis. The legs are scanned at multiple 
sites along the course of the deep veins. The 


TABLE 8 

Comparison of Cases With Normal SPG 
With the Venogram 


Venogram 

Number of Legs 

Per Cent 

Normal 

Incompetent Perforators 
(communicating veins) 

58 

5 

90.6%) 

)98.4% 

7.8%) 

Deep Vein Thrombosis 

1 

1.6% 

Total 

64 


TABLE 9 


Comparison of Cases With Positive SPG 
With Venogram 

Venogram N 

umber of Legs 

Per Cent 

Deep vein thrombosis 

25 

60% 

Incompetent perforators 
(communicating veins) 

15 

36% 

Normal 

2 

4% 

Total 

42 



144 


The West Virginia Medical Journal 


radioactive counts relative to cardiac back- 
ground activity are determined along each leg 
and compared to adjacent areas on that leg and 
to similar points on the opposite leg. A signifi- 
cant increase in count, 15 to 20 per cent relative 
to the same or opposite leg which persists on 
succeeding days, is indicative of venous throm- 
bosis. 

Discussion 

Five hundred, fifty patients had venous strain 
gauge plethysmography testing from November, 
1980, through March, 1982, at our laboratory. 
These patients had symptoms and signs sugges- 
tive of deep vein thrombosis. One hundred, six 
limbs had venograms, and 136 had 1-25 
fibrinogen leg scans, 94 with negative SPG and 
42 with positive SPG. The results are analyzed 
in Tables 8, 9, and 10. 

The fallibility of clinical diagnosis in cases 
of pulmonary emboli and venous thrombosis is 
approximately 50 per cent. 9 

Plethysmography involves the measurement of 
limb hemodynamics on the basis of changes in 
limb volume. 10 There are a variety of plethy- 
smographic methods available which include 
the mercury, water, air, impedance and strain 
gauge plethysmography. All of these techniques 
basically are designed to measure quantitatively 
either the rate at which blood is drained from 
the leg after a brief period of mechanically in- 
duced total venous occlusion or the degree to 
which the thrombosis interferes with the normal 
changes in venous volume that accompany 
respiration or pneumatic compression of the 
thigh. Plethysmographic methods will not detect 
an isolated clot in the hypograstric vein, deep 
femoral veins or small muscular veins. 

Barnes et al. have found the strain gauge 
plethvsmograph to be the most useful technique 
to quantitate the altered venous hemodynamics 
in not only acute deep vein thrombosis but also 
in the post-phlebitic syndrome and in primary 
and secondary varicose veins. ' 8 If the SPG is 
negative, exclusion of deep vein thrombosis can 
usually be made: however, if the SPG is positive. 


TABLE 10 

Comparison of Cases With Positive SPG and 
1-125 Fibrinogen Scan With Venogram 




Venograms 

Cases of DVT 

Number of Cases 


Incompetent 
DVT Perforators 

Normal 

Per Cent 

Positive SPG and 
Leg Scan 

24 

23 1 

0 

96% 

Positive SPG and 
negative Leg Scan 

18 

2 14 

2 

11% 

Total 

42 





either DVT or incompetent perforators (in- 
competent communicating veins with no throm- 
bosis) is likely to be present (96 per cent). 

The 1-125 fibrinogen leg scan effectively aids 
in differentiating those cases with positive SPG. 
When a positive SPG is combined with positive 
leg scan, the accuracy rate is 96 per cent true 
positive (23 of 24 legs). If the SPG is positive 
with negative leg scan, the diagnosis of in- 
competent perforators is most likely to occur ( 14 
of 18 legs, or 78 per cent). 

In conclusion, the SPG is a reliable test in 
excluding DVT (98 per cent). When combined 
with fibrinogen leg scan, it has a reliability rate 
of 96 per cent, but only 60 per cent are true 
positives when SPG is done alone. 

Summary 

This study analyzes the results of over 5,000 
patients studied in our noninvasive diagnostic 
vascular laboratory in the last four years. These 
included around 3,000 patients who had non- 
invasive carotid testing, mainly oculoplethy- 
smography ( OPG), with 1,080 arterial leg 
Doppler (ALD) tests for peripheral vascular 
occlusive disease (PVOD), 550 venous strain 
gauge plethysmography (SPG) for deep vein 
thrombosis (DVT), and about 1,000 other 
miscellaneous tests. 

We concluded that a combination of OPG/ 
Gee and real-time B-image scanning was the 
best noninvasive testing for the diagnosis of 
carotid artery stenosis. Arterial leg Doppler 
testing was very satisfactory in the diagnosis of 
peripheral vascular occlusive disease. The venous 
strain gauge plethlysmograph was excellent in 
excluding cases of deep vein thrombosis. 

Acknowledgments 

We wish to thank Gordon Gee, Supervisor of 
Biomedical Photography, West Virginia Univer- 
sity Medical Center, Morgantown, and Bill 
Hogan, Graphic Arts Designer, Charleston Di- 
vision, WVU Medical Center, for their coopera- 
tion with illustrations used in this article. 

References 

1. AbuRahma AF, Boland J, Diethrich EB: Correla- 
tion of the resting and exercise Doppler ankle/ arm index 
to angiographic findings. Angiology 1980; 31:331-336. 

2. AbuRahma AF, Diethrich EB: Diagnosis of carotid 
arterial occlusive disease. Vase Surg 1980; 14:23-29. 

3. AbuRahma AF, Diethrich EB: Doppler testing in 
peripheral vascular occlusive disease. Surg Gynecol 
Obstet 1980; 150:26-28. 

4. AbuRahma AF, Diethrich EB: Doppler ultrasound 
in evaluating the localization and severity of peripheral 
vascular occlusive disease. South Med ] 1979; 72:1425- 
1428. 


July, 1983, Vol. 79, No. 7 


145 


5. AbuRahma AF, Diethrich EB: The yield and re- 
liability of oculoplethysmography and carotid phono- 
angiography in stroke screening and the diagnosis of 
extracranial carotid occlusive disease. W Va Med J 1979; 
75:254-260. 

6. AbuRahma AF, Lawton WE Jr, Boland J, Diethrich 

EB: Correlation of the resting and exercise Doppler 

ankle/ arm index to the symptomatology and to the 
angiographic findings, in: N oninvasive Assessment of the 
Cardiovascular System, Wright-PSG, Inc, 1982. 

7. Barnes RW, Collicott PE, Sumner DS et ah: Non- 
invasive quantitation of venous hemodynamics in the 
postphlebitic syndrome. Arch Surg 1973; 107:807. 

8. Barnes RW, Ross EA, Strandness DE Jr.: Dif- 

ferentiation of primary from secondary varicose veins by 
Doppler ultrasound and strain gauge plethysmography. 
Surg Gynecol Obstet 1975; 141:207. 

9. Dalen JE, Dexter L: Pulmonary embolism. JAMA 
1969; 207:1505. 

10. Dohn K: Plethysmography during functional 

states for investigation of the peripheral circulation, pro- 
ceedings of the Second International Congress of Physics, 
Copenhagen, 1957. Dansk Fysiurgisk Selskab, p 51. 


11. Gee W, Oiler DW, Homer LD, Bailey CR: Simul- 
taneous bilateral determination of the ophthalmic arteries. 
Inves Ophthalmol Vis Set 1977; 16:86-89. 

12. Kartchner MM, McRae LP, Crain V et ah: Oculo- 
plethysmography: An adjunct to arteriography in the 

diagnosis of extracranial carotid occlusive disease. Am J 
Surg 1976; 132:728-738. 

13. Malone JM, Bean B, Laguna J et al.: Diagnosis 
of carotid artery stenosis. Ann Surg 1980; 191:347-354. 

14. McDonald PT, Rich NM, Collins GJ et ah: Dop- 
pler cerebrovascular examination, OPG and ocular pneu- 
moplethysmography. Arch Surg 1978; 113:1341-1349. 

15. Stegall HF, Rusfmier RF, Baker DW: A trans- 
cutaneous blood velocity meter. J Appl Physiol 1966; 
21:707-711. 

16. Winsor T: The influence of arterial disease on 
the systolic blood pressure gradients of the extremity. 
Am J Med Sci 1950; 220:117. 

17. Yao JST, Bergan TJ: Application of ultrasound to 
arterial and venous diagnosis. Surg Clin North Am 1974; 
54:23-27. 


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146 


The West Virginia Medical Journal 



Tuberculosis After Jejunoileal Bypass Surgery* 


LEEMAN P. MAXWELL. M. D. 

Fellow in Cardiology , Department of Medicine, West 
Virginia University School of Medicine, Morgantown 

RASHIDA A. KHAKOO, M. D. 

Associate Professor of Medicine, WVU School of 
Medicine, Morgantown 

EDWIN J. MORGAN, M. D. 

Professor of Medicine, WVU School of Medicine, 
Morgantown 


A young man underwent jejunoileal bypass 
surgery for morbid obesity. He later developed 
disseminated tuberculosis. There is increased 
risk of tuberculosis following this type of surgery 
as tvell as post-gastrectomy. These patients 
should be screened for tuberculosis prior to sur- 
gery and folloived closely post-operatively for this 
complication. 

Case Report 

A white male in his early thirties underwent 
greater than 90-per cent jejunoileal bypass for 
morbid obesity in 1979. He did well, losing ap- 
proximately 200 pounds ( over 50 per cent of his 
pre-operative weight ) . About two years later, 
he noted weakness, easy fatigability, generalized 
arthralgias and myalgias, with nightly fevers, 
chills and sweats. He also unintentionally began 
to lose more weight. His surgeon evaluated him 
for lymphoma when a mediastinal mass was noted 
on chest x-ray. A lymphangiogram and abdom- 
inal CT scan showed diffuse lymphadenopathy. 
Sternotomy demonstrated a benign thymic cyst 
with numerous noncaseating granulomas. This 
tissue was not cultured. A positive purified pro- 
tein derivative (PPDl was overlooked. 

Approximately one year ago, the patient was 
admitted to West Virginia University Hospital 
in moderate distress and malnourished. An inter- 
mediate-strength PPD produced 25 mm of in- 
duration at 24 hours. The mediastinal mass as 
well as a right apical infitrate were seen on chest 
roentgenogram (Figure). Axillary lymph node 
biopsy demonstrated caseating granulomas. Cul- 
tures from both the sputum and lymph node grew 
Mycobacterium tuberculosis. Liver, urine and 
bone marrow cultures were negative. 

The patient’s symptoms resolved and he began 
to gain weight after treatment with isonicotine 
hydrazine ( INH ) , ethambutol. and rifampin. 
Serial serum drug levels documented adequate 
therapy (Table). 

“This paper was written while Doctor Maxwell was a 
resident in medicine. West Virginia University School of 
Medicine, Morgantown. 


Discussion 

Eighteen patients with tuberculosis compli- 
cating intestinal bypass surgery were reported in 
the literature between 1969 and 1980. This rep- 
resents an incidence of one to four per cent, de- 
pending on the study, 1 and a greater than 63- 
fold increase (estimated) in the risk of tuber- 
culosis over the general population. 2 

These patients more often present with extra- 
pulmonary tuberculosis, most commonly with 
lymph node involvement. The symptom com- 
plex of accelerated weight loss, lymphadeno- 
pathy, and unexplained fever suggests tuberculo- 
sis. The average time to onset of symptoms fol- 
lowing bypass is 16 months. 3 This length of time 



Figure. Left subclavian lymph nodes are seen 
with lymphangiogram contrast dye. The mediasti- 
num is wide. The right apex and partachael area 
demonstrate pulmonary involvement. 

TABLE 

Serum Levels of Oral Antituberculosis Drugs 

DRUG INH Ethambutol Rifampin 

DOSE 400mg 30mg/kg 1200mg 

THERAPEUTIC 0.4-4.0 3-12 10-40 

RANGE (mcg/ml) 

TIME SERUM CONCENTRATION (mcg/ml) 


1 hr 

6.5 

— 


2 hrs 

— 

7.55 

15.4 

3 hrs 

— 

— 

11.6 

4 hrs 

5.2 

3.17 

6.2 


July, 1983, Vol. 79, No. 7 


147 


is usually coincident with the phase of rapid 
weight loss which occurs post-operatively . 4 

The association of pulmonary tuberculosis 
after gastrectomy with malabsorption has been 
well-documented . 2,3 Malnutrition with weight 
loss and its sequelae of immunosuppression is 
considered an important factor in the increased 
susceptibility to tuberculosis . 2 Lymphocyte 
transformation in the presence of specific antigen 
in intestinal bypass patients with tuberculosis 
gave positive but less energetic responses than 
normal controls . 2 

These data suggest that these patients cannot 
defend themselves normally against tuberculosis, 
especially during the period of rapid weight loss. 

The other major problem in these patients is 
assuring adequate therapy because of decreased 
absorptive surface and rapid transit. Ethambutol 
is absorbed from the stomach and proximal 
jejunum. Rifampin participates in an entero- 
hepatic circulation with proximal absorption in 
the stomach with biliary excretion and jejunal 
reabsorption. Therefore, serum levels of these 
drugs should be done to document adequate 
therapy . 2 Our patient is only the third patient re- 
ported to have documented adequacy of treat- 
ment with serum drug levels. 


Yu 3 recommends that all patients being con- 
sidered for this surgery undergo intermediate 
PPD prior to surgery. If positive and no disease 
is found, he recommends one year of treatment 
with INH. as is done with post-gastrectomy pa- 
tients. 

These patients illustrate the need to be aware 
of the increased risk of tuberculosis following 
jejunoileal bypass surgery. They should receive 
INH prophylaxsis for one year following surgery 
if the PPD is positive. Finally, serum drug levels 
are necessary to ensure adequate therapy. 

Acknowledgements 

Lederle Laboratories and Merrell Dow Phar- 
maceuticals for performing the drug assays. 

References 

1. Doldi SB: Tuberculosis after intestinal bypass for 
morbid obesity, Int Surg 1980; 65:131-134. 

2. Bruce RM, Wise L: Tuberculosis after jejunoileal 
bypass for obesity. Ann Intern Med 1977; 87:574-576. 

3. Yu VL: Onset of tuberculosis after intestinal by- 
pass surgery for obesity. Arch Surg 1977; 112:1235-1237. 

4. Bray GA, Barry RE, Benfield JR, Castelnuevo- 

Tedesco P, Drenick EJ, Passaro E: Intestinal bypass 

operation as a treatment for obesity. Ann Intern Med 
1976; 85:97-109. 


Conservative Treatment Recommended 

A large-scale study by surgeons and physicians at Houston’s M.D. Anderson Hos- 
pital suggests that conservative surgery and irradiation are viable alternatives to 
radical mastectomy for selected patients with early breast cancer. 

Writing in a recent issue of Archives of Surgery, Marvin M. Romsdahl, M.D., Ph.D., 
and colleagues report that 922 patients were followed from 1955 through 1979 in a 
study that compared conservation surgery and irradiation with radical or modified 
radical mastectomy in the treatment of minimal, stage I and stage II breast cancer. 

“Disease-free survival rates at five and 10 years for patients having radical mas- 
tectomy or conservation surgery with irradiation are similar,” the researchers say. 


148 


The West Virginia Medical Journal 


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July, 1983, Vol. 79, No. 7 


149 



*Jke President 


2J 



THE ROLE OF OUR ORGANIZATION 


S ometimes in the stress of day-to-day medical 
practice, amid the complexities of modern- 
day life, we tend to lose track of the original 
goals and purposes of our organization. Indeed, 
some of us may have forgotten or never have 
known of them. It is refreshing and enlighten- 
ing now and again to look back at our stated 
purposes. To this end I quote the pertinent 
section of our constitution. 

Article II, Section 1 of the Constitution of the 
West Virginia State Medical Association states 
“the purposes of this association shall be to 
federate and bring into one compact organiza- 
tion the entire medical profession of the state of 
West Virginia, and to unite similar associations 
or societies of other states to form the American 
Medical Association; to extend medical knowl- 
edge and advance medical science; to promote 
the public health; to elevate the standards of 
medical education; to secure the enactment and 
enforcement of just medical laws; to promote 
the general welfare of physicians; and to en- 
lighten and direct public opinion in regard to 
the problems of state medicine so that the pro- 
fession shall become more capable and honor- 
able within itself, and more useful to the public 
in the prevention and cure of disease and in 
prolonging life and adding comfort thereto.” 

At the risk of “preaching to those already in 
church,” I would like to reflect for a bit on some 
of the stated purposes of our organization — “to 
bring into one compact organization the entire 
medical profession of the state of West Vir- 
ginia.” This means membership. It is important 
to bring all the practitioners of our profession 
into the membership of our Association so that 
we may indeed speak as one united voice. Our 
Association, like any other, constantly gains and 
loses members. New practitioners move into 
the state; others leave the state or retire. It is 
vitally important that we encourage newer 
practitioners and other non-members to unite 
with us in membership so that our Association 
may fulfill its purpose of representing the entire 
medical profession of West Virginia. 

“To extend medical knowledge and advance 
medical science.” “To promote the public 


health.” “To elevate the standards of medical 
education and to secure the enactment and en- 
forcement of just medical laws.” Without an 
active and involved, representative Association 
to achieve these goals, one individual practi- 
tioner has but limited resources to use in an at- 
tempt “to promote the general welfare of physi- 
cians and to enlighten and direct public opinion 
— so that the profession shall become more use- 
ful to the public in the prevention and cure of 
disease and in prolonging life and adding com- 
fort thereto.” 

Without the resources of our Association, the 
individual would find this an almost insur- 
mountable task, but, paradoxically, the Associa- 
tion cannot survive without the resources and 
actions of individual members. There is a sym- 
biosis between the organization and the actions 
of the individuals within that organization. One 
cannot survive without the other. Accordingly, 
as individual members, we must continue to at- 
tract other individuals to the organization to 
increase its strength and resources for our 
mutual benefit. 

We members cannot rely only on our office 
staff to carry out all the activities needed to pro- 
mote the goals of our Association. The re- 
sources of our office are many and are there for 
the members to use, but our six staff members 
cannot respond to inquiries from the press, 
legislature, and others, publish The Journal, in- 
fluence all the necessary lawmakers, run the in- 
surance program, schedule and operate the 
CME activities and meetings, etc., without help 
from us, the members. They can provide the 
resources but it is up to us to provide the action. 
If we do not, our goals will not be met. I look 
forward to seeing each of you at our Annual 
Meeting to provide that action! 


Harry Shannon, M. D., President 
West Virginia State Medical Association 








150 


The West Virginia Medical Journal 


The Vest Virginia Hedical Journal 

Editorials 

The Publication Committee is not responsible for the authenticity of opinion or statements made by authors or 
in communications submitted to this Journal for publication. The author shall be held entirely responsible. 
Editorials printed in The Journal do not necessarily reflect the official position of the West Virginia State 
Medical Association. 


Despite the furor, confusion and complexity 
of modern living, Gerald C. Kempthorne, M. D., 
President of the State Medical Society of 
W isconsin, always returns to one fundamental 
premise. Despite the changing atmosphere sur- 
rounding the practice of Medicine, he recently 
noted, “I find physicians are continuing to do 
what they have always done — practice quality 
medicine for the patients they are committed to 
serve.” 

“Certainly, the delivery systems have changed 
dramatically,” Doctor Kempthorne wrote in the 
Wisconsin Medical Journal. “However, I have 
seen no diminution in the 
QUALITY physician’s fervor in continu- 

COMMITMENT ing the role of patient’s advo- 
cate. In view of the rapidly 
changing scene, the one solid profession behind 
the welfare of the patient is the House of 
Medicine. Schemes and scenarios may come and 
go, but when the dust settles, the physician will 
he there, as usual, caring for his or her patient." 

The Wisconsin President has emphasized, con- 
sistent with general thinking reflected in con- 
tinuing medical education programs and other- 
wise, that keeping up is an important part of the 
profession. There is, he said, no other health 
caring profession which can demonstrate more 
effectively the advances in human health care 
than what we have witnessed in Medicine. 

“We are now able to diagnose serious illness 
without dangerous invasion of the body,” Doctor 
Kempthorne observed. “There is hardly a con- 
dition of the human body we cannot treat in one 
manner or another with varying degrees of suc- 
cess. People want expert medical care, and it 
has been laid at the doorstep of every patient.” 

“Essentially, most people want freedom from 
disease, and long life,” he continued. “Is that 
an unreasonable aspiration? Only recently have 
people begun to do their part with efforts at 
wellness and prevention of disease. Until the 
long-term benefit from that activity arrives, 


society still will be faced with the need to treat 
disease and illness.” 

Touching on a theme common everywhere, 
and getting varying degrees of legislative and 
other attention. Doctor Kempthorne noted that 
“virtually no obstacles stood in the way of 
achieving the long, good life until it was finally 
recognized that it really does cost money to 
underwrite such an ambitious endeavor." He 
added : 

“Now, the realization is upon us that optimal 
medical care is costly. Who wants to say that 
we should de-emphasize the importance of a 
long, healthy life? If it takes 10 per cent of the 
gross national product in order to assure that 
quality of life, is that had, even if we could be 
more efficient in the system?” 

Doctor Kempthorne also stressed that to 
malign the hospital system and physicians in 
America as the culprits of the escalating cost 
scenario is far too simple. The current preoccu- 
pation with health care costs won’t mean much 
unless society at large decides to take an active 
role. 

Now. let’s let Doctor Kempthorne take it from 
here against a background of some of the think- 
ing and legislative activity which recently has 
come to the front in West Virginia: 

“If health care is to be optimal in all circum- 
stances, then there will be a substantial price tag 
attached, despite all efforts at economizing. Will 
someone have the bravery to suggest that ordi- 
nary or adequate care is good enough? If we 
can't afford optimal care, who will suggest ration- 
ing? Can you imagine writing guidelines for 
limits on medical care because of the cost? 
Currently, it is fashionable to ‘penalize’ the poor 
by requesting a copayment for services after 
giving them a medical card because they couldn’t 
afford medical care in the first place. 

“Until we can ‘cure’ the insatiable appetite for 
optimal health care by all of us, we are truly 
facing an enigma. We (meaning our social 
order ) have virtually encouraged all of our 
citizens to seek optimal care in the past. Now 


July, 1983, Vol. 79, No. 7 


151 



we are ‘hinting’ that we can't afford it, and we 
are spending a lot of time and effort to find 
the cause of the problem we created in the first 
place. 

“The current ‘cost of health care’ is much like 
a red ink jigsaw puzzle without form. There are 
so many parts in the faceless form that it makes 
it difficult and depressing to try to put it all 
together. Experts and ideas will come and go to 
solve the amorphous riddle. Whatever set of 
principles finally evolves, the medical profession 
will remain at the ‘bedside’ of the patient and 
never abandon his or her calling, despite the cry 
from the outside." 


A heartening trend in patient care continues 
in West Virginia, and in fact appears to be 
picking up still more momentum. Fifteen of the 
20 family physicians completing their residency 
training this summer are remaining in the state. 
That’s 75 per cent, about the ongoing figure for 
that particular program. 

Increased numbers of West Virginia Uni- 
versity School of Medicine graduates are practic- 
ing here after completing their 
NEW training. That percentage is near 

RESOURCES 50 since 1974. Early indications 
are that the same general pattern 
will develop with graduates from the Marshall 
LIniversity School of Medicine. 

In addition. West Virginians who have been 
practicing or in training elsewhere are coming 
back in noticeable numbers. They are return- 
ing from such points as South Carolina and 
Texas, and going to such counties as Summers 
and Pocahontas. 

This is the time of the year in which, across 
the nation, many young doctors complete resi- 
dencies and enter into practice. They begin 
a challenging and fascinating new phase of their 
careers — and one which also is certain to bring 
some frustration and adjustment problems. 

We trust, in West Virginia, that our medical 
communities will welcome these new colleagues, 
and stand ready to assist and counsel them. We 
need their knowledge and skills, and their move- 
ment to rural and so-called physician shortage 
areas, in particular, must be further encouraged. 

Clearly, some of the young doctors will find 
that their training, heavily weighted in scientific 
knowledge, has left something to be desired in 
the social, economic, legal and political aspects 
of medical practice, and of the complex health 
care system in which they will work. 


They will be faced with the specific challenge 
of always trying to do what is best for their 
patients in a very cost-sensitive health care en- 
vironment. 

The new doctors will find society confused 
about what to do about health care and its rising 
cost. Society wants more health care for more 
people and equal access for all to high quality 
care, but is balking at the expense. 

It’s important for all physicians, old and new, 
never to forget that their primary obligation is 
the historic responsibility of doctor to patient. 
This always must come ahead of any business 
or corporate obligations. 


The Missouri State Medical Association, 
through its Journal, recently reminded its mem- 
bers that most groups appearing before the 
Missouri General Assembly are “single issue" 
in nature. 

These groups, despite small numbers, organize 
very effective campaigns to gain 
SINGLE ISSUE approval of their particular 
objective. They work hard to 
make personal contact with each representative 
and senator. 

Physicians, meanwhile, apparently have come 
to believe that someone else will take care of 
their interests in this bothersome (legislative) 
area — and they are wrong, the Missouri Journal 

stressed. 

Legislators, it added, are going to vote accord- 
ing to the wishes of the constituents who contact 
them. If physicians choose not to be heard, they 
won’t be! 

Does all this sound familiar? It should. It 
simply echoes what the West Virginia State 
Medical Association leadership has been saying 
over and over again. Instead of “single issue” 
we've used the words “single shot." But the les- 
son is the same. 

While one particular group is working on one 
bill, an organization such as the Medical Associa- 
tion will be monitoring or dealing to some degree 
with 100 or more. Staff and other resources 
accordingly are thinly spread. 

Without more and more physician interest and 
input, concerns of this Association and the 
patients for whom it is the advocate are in 
trouble. And as they say in Missouri, if physi- 
cians choose not to be heard, they won’t be. 


152 


Thf. West Virginia Medical Journal 


GENERAL NEWS 


Convention Symposium To Eye 
Cardiovascular Disease 

Cardiovascular surgery and cardiac arrhyth- 
mias will be among subjects discussed in a 
“Symposium on Cardiovascular Diseases” during 
the 116th Annual Meeting of the State Medical 
Association. 

The speakers on the above two subjects, it 
was announced by the Program Committee, will 
be Drs. John C. Alexander, Jr., of Morgantown, 
whose topic will be “Cardiovascular Surgery — 



John C. Alexander, Jr., M. D. Stafford G. Warren, M. D. 


An Update;” and Stafford G. Warren, Charleston 
cardiologist, “New Developments in the Man- 
agement of Cardiac Arrhythmias.” 

The symposium, which also will include a 
paper on congestive heart failure, will constitute 
the second general scientific session of the con- 
vention Saturday morning, August 27. 

The Annual Meeting will be held August 25-27 
at the Greenbrier in White Sulphur Springs. 

Doctor Alexander is Associate Professor of 
Surgery and Chief, Section of Cardiothoracic 
Surgery at the West Virginia University School 
of Medicine. 

Doctor Warren is Clinical Professor of Medi- 
cine at WVU Charleston Division. 

The Annual Meeting will open with a pre- 
convention session of the Association’s Council 
and the first session of the House of Delegates 
on Thursday morning and afternoon, August 25: 
and end with the second and final House session 


and reception for Association members and 
guests Saturday afternoon, and a dinner that 
evening I see story on page 154 for details). 

Doctor Adkins to be Installed 

At the final House session on Saturday after- 
noon, Dr. Carl R. Adkins of Fayetteville will 
he installed as the Association’s 1983-84 Presi- 
dent to succeed Dr. Harry Shannon of Parkers- 
burg. 

Dr. Frank J. Jirka, Jr., President of the 
American Medical Association, as announced 
previously, will address the first House session 
on Thursday. He is from Barrington, Illinois. 

Dr. Samuel P. Asper of Philadelphia, also as 
announced, will deliver the keynote Thomas L. 
Harris address during opening exercises Friday 
morning preceding the first general scientific ses- 
sion. Doctor Asper, who is President of the 
Educational Commission for Foreign Medical 
Graduates, will speak on “Strengths and Weak- 
nesses of the U. S. Role in International Medi- 
cine.” 

First Scientific Session 

Friday morning speakers and topics for the 
first general scientific session, a “Symposium on 
Sexually Transmitted Diseases,” will be: 

“Syphilis and Gonococcal Infections” — Dr. 
Edmund C. Tramont (colonel, U. S. Army Medi- 
cal Corps), Chief, Infectious Diseases, Depart- 
ment of Bacterial Diseases, Walter Reed Army 
Institute of Research, Washington, D.C.; and 
Associate Professor of Medicine and Coordi- 
nator (Chief), Division of Infectious Diseases, 
Uniformed Services University of the Health 
Sciences Medical School. Bethesda. Maryland: 
“Non-Luetic, Non-Gonococcal Venereal Dis- 
eases” — Dr. Lee P. Van Voris, Chief, Infectious 
Diseases, and Epidemiologist at Hamot Hospital, 
Erie. Pennsylvania I formerly Associate Professor 
of Medicine, Marshall University School of 
Medicine I ; 

“Transmissible Diseases of the Gay Patient" 
— Dr. George J. Pazin, Associate Professor of 
Medicine, University of Pittsburgh; and “Sexual 
Mores in the 1980s” — Dr. Jack L. Summers, 
Chairman, Department of Urology, Akron 
(Ohio) City Hospital, and Professor, Depart - 


July, 1983, Vol. 79, No. 7 


153 


ment of Urology, Northeastern Ohio Universities 
College of Medicine, Akron. 

In addition to the House and general sessions, 
the Annual Meeting agenda will include break- 
fast, luncheon and other programs arranged by 
specialty societies and sections, many of which 
also will provide scientific discussions. 

Scientific Exhibits 

Scientific exhibits, again to be housed in 
Eisenhower Hall, will be open from 1 to 5 P. M. 
on Thursday, and from 8:30 A. M. to noon on 
Friday and Saturday. The exhibits will be listed 
in the August issue of The Journal. In order to 
provide convention registrants with ample oppor- 
tunity to visit the exhibits, coffee breaks for that 
purpose have been scheduled during the general 
scientific session Friday and Saturday mornings. 
The scientific sessions will he held in the theater, 
which adjoins Eisenhower Hall. 

Doctor Alexander came to WVU in 1982 from 
Cornell University, where he was Assistant Pro- 
fessor of Surgery. 

A native of Durham, North Carolina, he was 
graduated from Duke University, and received 
his M. D. degree in 1971 from the University’s 
School of Medicine. He was the recipient of an 
Early Internship at Duke in 1971-72, completing 
his residency there and at the Surgery Branch, 
National Cancer Institute, National Institutes of 
Health, Bethesda, Maryland. 

Doctor Alexander was a Teaching Scholar at 
Duke in 1979-80 before going to Cornell. 

University of Rochester Graduate 

Doctor Warren is certified in internal medicine 
and cardiology, and is a Fellow of the American 
College of Cardiology. He was graduated from 
Davidson ( North Carolina ) College, did a year 
of graduate work at Wesleyan University in 
Middletown, Connecticut, and then entered the 
University of Rochester School of Medicine, 
receiving his M. D. degree in 1969. 

He interned at the University Hospital of 
Cleveland, and completed postgraduate studies 
there and at Duke University. 

Doctor Warren is a member of the active staff 
at Charleston Area Medical Center (CAMC), 
and was the 1975 recipient of a research grant 
from Medical Associates (CAMC) for a CPK 
isoenzyme study. 

He is the author or co-author of some 13 
scientific publications. 

The Auxiliary to the State Medical Associa- 
tion, with Mrs. Richard S. Kerr of Morgantown 


the current President, as usual will hold its 
meeting in conjunction with that of the Associa- 
tion. 

1983 Program Committee 

Members of the 1983 Program Committee 
are David Z. Morgan, M. D., Morgantown, 
Chairman; Doctor Adkins; Jean P. Cavender, 
M. D., Charleston; Michael J. Lewis, M. D.. St. 
Marys; Kenneth Scher, M. D., Huntington, and 
Roland J. Weisser, Jr., M. D., Morgantown. 

The official convention program, and infor- 
mation concerning remaining speakers and other 
details will be provided in the August issue of 
The Journal. 


Saturday Convention Dinner 
Added To Schedule 

As noted in the June issue of The Journal, 
the Medical Association’s Annual Meeting 
Program at the Greenbrier will be enhanced 
this year by a black-tie dinner to honor out- 
going and new leaders of the Association and 
Auxiliary. 

This dinner, a “by-ticket only” innovation, 
is scheduled for Saturday evening, August 27. 
It will be held in Chesapeake Hall and will be 
the convention’s last event, following the 
second and final House of Delegates meeting. 

The dinner will enable the Association and 
Auxiliary leadership to offer comments, in a 
largely informal style, they feel pertinent as to 
the organizations’ activities, objectives and the 
like. Invited guests will include the Presidents 
and spouses of the American Medical Associa- 
tion, and neighboring states represented each 
year. 

It might be necessary for some of those who 
have made their hotel reservations to review 
them in the light of plans they might revise 
to attend the Saturday dinner. 

Current plans call for dinner tickets to be 
on sale at the Association and Auxiliary regis- 
tration desks, beginning on Thursday morn- 
ing, August 25. It will be necessary to pro- 
vide the Greenbrier with an attendance 
guarantee by late on Friday, August 26. 

At this writing, planning for the dinner is 
continuing, and the membership will be kept 
advised as other details fall into place. Mean- 
while, if any physicians already have plans to 
attend, and desire to advise the Association 
office, P. 0. Box 1031, Charleston 25324, 
that advance information would be helpful. 


154 


The West Virginia Medical Journal 


Continuing Education 
Activities 


Here are the continuing medical education 
activities listed primarily by the West Virginia 
University School of Medicine for part of 
1983, as compiled by Dr. Robert L. Smith, 
Assistant Dean for Continuing Education, and 
J. Zeb Wright, Ph. D., Coordinator, Con- 
tinuing Education, Department of Community 
Medicine, Charleston Division. The schedule is 
presented as a convenience for physicians in plan- 
ning their continuing education program. (Other 
national, state and district medical meetings are 
listed in the Medical Meetings Department of 
The Journal. ) 

The program is tentative and subject to 
change. It should be noted that weekly confer- 
ences also are held on the Morgantown, Charles- 
ton and Wheeling campuses. Further information 
about these may be obtained from: Division of 
Continuing Education. WVU Medical Center, 
3110 MacCorkle Avenue, S. E., Charleston 
25304: Office of Continuing Medical Education. 
WVU Medical Center, Morgantown 26506; or 
Office of Continuing Medical Education, Wheel- 
ing Division. WVU School of Medicine, Ohio 
Valley Medical Center. 2000 Eofl Street. Wheel- 
ing 26003. 

Sept. 3. Morgantown, Treatment Options in 
Arthritis 

Sept. 9-10, Morgantown, Ob/Gyn Teaching 
Days 

Sept. 14, Charleston. Advances in Hypertension 

Regularly Scheduled Continuing 
Education Outreach Programs from 
WVU Medical Center/ 
Charleston Division 

Buckhannon . St. Joseph’s Hospital, first-floor 
cafeteria, 3rd Thursday. 7-9 P. M. — July 
( summer break ) . 

Cabin Creek, Cabin Creek Medical Center, 
Dawes. 2nd Wednesday, 8-10 A. M. — July 13, 
“Headaches,” A. L. Poffenbarger. M. D. 

Cassaway, Braxton Co. Memorial Hospital. 1st 
Wednesday, 7-9 P. M. — July 6, “The Phar- 
macology of Hypertension Management,” 
Stephen Grubb, M. D. 

Aug. 3, “Diagnosis of Pulmonary Disorders,” 
Dominic Gaziano, M. D. 


Madison, 2nd floor, Lick Creek Social Services 
Bldg., 2nd Tuesday, 7-9 P. M. — July 12, 
“Approach to the Peripheral Vascular Pa- 
tient,” Ali F. AbuRahma, M. D. 

Oak Hill, Oak Hill High School (Oyler Exit, N 
19) 4th Tuesday, 7-9 P. M. — July (summer 
break ) . 

Welch, Stevens Clinic Hospital, 3rd Wednesday, 
12 Noon-2 P. M. — July (summer break). 

Whitesville, Raleigh-Boone Medical Center, 4th 
Wednesday, 11 A.M.-l P.M. — July-August 
(summer break) 

Williamson, Appalachian Power Auditorium, 1st 
Thursday, 6:30-8:30 P. M. — July (summer 
break I . 


Alzheimer’s Disease Autopsies 
Needed, Researcher Urges 

A California pathologist calls for more autop- 
sies of Alzheimer's disease victims to assist 
researchers investigating this puzzling and dev- 
astating disorder. 

“Despite its past anonymity, Alzheimer’s dis- 
ease is a killer that strikes over 1.5 million 
Americans and causes about 50 per cent of all 
nursing home admissions, at a staggering annual 
cost of $20 billion,” said George G. Glenner, 
M. D., in an editorial in a recent issue of 
Archives of Pathology and Laboratory Medicine. 

The University of California, San Diego, re- 
searcher said the National Alzheimer’s Disease 
Brain Bank at his institution emphasizes the need 
for autopsies to obtain adequate material for 
research investigations on the disease, as well as 
to offer families an accurate diagnosis. Since a 
genetic component for the disease has been sug- 
gested, families can gain helpful information 
through accurate diagnosis of the cause of death 
of aged parents who had symptoms resembling 
Alzheimer’s disease. 


Thyroidectomy Speaker 

Dr. Romeo Y. Lim of Charleston spoke on 
“Emergency Thyroidectomy for Tracheal Ob- 
struction" at the New York University “Otolaryn- 
gology Update ’83” in June in New York City. 
Doctor Lim is Clinical Associate Professor of 
Otolaryngology — Head and Neck Surgery at 
West Virginia University, and an active staff 
member of the Eye and Ear Clinic of Charles- 
ton. 


July, 1983, Vol. 79, No. 7 


155 



Reference Manual Offered 
By Cancer Society 

Cancer Manual, a cancer reference text, now 
is available from the West Virginia Division of 
the American Cancer Society. 

The 444-page manual provides a fundamental- 
ly pragmatic approach to the problems of pa- 
tients with specific cancers. It also includes many 
contemporary issues such as those dealing with 
psychosocial aspects, sexuality, nutrition, hospice 
concepts, and the role of nurses and social work- 
ers. 

As such, the Cancer Society commented, this 
book should be of interest to practicing physi- 
cians, interns, residents, medical students, nurses, 
and all others involved in cancer care. It can be 
used as a desk-top reference for history and 
physical examination techniques, diagnostic prin- 


Review A Book 


The following books have been received by the 
Headquarters Office of the State Medical Associa- 
tion. Medical readers interested in reviewing hny 
of these volumes should address their requests to 
Editor, The West Virginia Medical Journal. Post 
Office Box 1031, Charleston 25324. We shall he 
happy to send the hooks to you, and you may 
keep them for your personal libraries after sub- 
mitting to The Journal a review for publication. 

Current Medical Diagnosis and Treatment , 
1083, edited by Marcus A. Krupp, M. D.; and 
Milton J. Chatton, M. D. 1130 pages. Price $24. 
Lange Medical Publications, Los Altos, Cali- 
fornia 94022. 1983. 

General Ophthalmology, 10th Edition, by 
Daniel Vaughan, M. D.; and Taylor Asbury, 
M. D. 407 pages. Price $17. Lange Medical 
Publications, Los Altos, California 94022. 
1983. 

Neuroanatomy: An Atlas of Structures, Sec- 
tions, and Systems, by Duane E. Haines, Ph.D., 
Professor of Anatomy, West Virginia LIniversity 
School of Medicine, Morgantown. 212 pages. 
Price $19.50. Urban & Schwarzenberg Medical 
Publishers, 7 East Redwood Street, Baltimore, 
Maryland 21202. 1983. 

Review of Medical Physiology, 11th Edition, 
by William E. Ganong, M. D. 643 pages. Price 
$20. Lange Medical Publications, Los Altos, 
California 94022. 1983. 


ciples, and epidemiology of cancer sites. In- 
formation on pathology, the various treatment 
modalities, and rehabilitation techniques also are 
covered. 

The book can be obtained by sending a check 
for $4, payable to American Cancer Society, 
West Virginia Division, Inc., to the Society at 
240 Capitol Street - Suite 100, Charleston 25301. 


Doctor Santrock Elected 
WVU Alumni Head 

Dr. David A. Santrock of Charleston recently 
was elected the 82nd President of the West Vir- 
ginia University Alumni Association during 1983 
alumni/commencement weekend activities. 

Doctor Santrock, an orthopedic surgeon, re- 
ceived a B. S. degree in 1963 from WVU, and 
his M. D. degree in 1967 from the University’s 
School of Medicine. He has been a member of 
the Alumni Association Executive Council since 
1980. 

Elected Vice President was Lucy Bowers 
Eilson, 1950, of Beckley, civic and alumni leader. 



Dr. Stanley J. Kandzari of Morgantown, first row, 
left, was installed as President of the West Virginia 
Chapter, American College of Surgeons at its spring 
meeting held at the Greenbrier. Other officers 
shown are, from left, front row, Sharon Bartholo- 
mew, Morgantown, Executive Secretary, and Drs. 
Catalino B. Mendoza, Jr„ Clarksburg, President 
Elect, and William R. McCune, Martinsburg, Coun- 
cilor; second row, Drs. Roger E. King, Morgantown, 
First Vice President, and William E. Gilmore, Park- 
ersburg, Councilor; third row, Drs. Billie M. Atkin- 
son, Parkersburg, and James A. Coil, Jr„ Hunting- 
ton, Councilors. Dr. Herbert G. Dickie, Jr„ of 
Wheeling is Governor, and Dr. Alvin L. Watne of 
Morgantown, Secretary-Treasurer. 


156 


The West Virginia Medical Journal 




1983 Scholarship Winners 
Named By Committee 

The West Virginia State Medical Association 
has awarded to another four state students four- 
year scholarships to the West Virginia University 
and Marshall University Schools of Medicine. 
Each scholarship is worth $1,500 annually, or 
$6,000 total. 

Here are the 1983 selections of the Associa- 
tion’s Committee on Medical Scholarships, as 
announced by the Committee Chairman. John 
Mark Moore, M. D., of Wheeling, after an annual 
Committee meeting early in June in Bridgeport: 

William M. Skeens of Huntington, who will 
enter MU School of Medicine this fall; and Debra 
Sue Hinzman of Harrisville, Susan Marie Sypolt 
of Terra Alta, and John L. Stanley of Fayette- 
ville, who will be first-year students at the WVU 
School of Medicine. 

Married and the father of two children, Skeens 
received a B. S. degree in chemistry at MU this 
past spring. He is the son of Mr. and Mrs. Wil- 
liam C. Skeens, Jr., of Barboursville. 

Biology Degree 

Miss Hinzman. the daughter of Mr. and Mrs. 
Luther H. Hinzman of Harrisville, was graduated 
this spring from WVU with a B. S. degree in 
biology. 

Miss Sypolt received a B. A. degree in chem- 
istry this spring at WVU. She is the daughter of 
Mr. and Mrs. Robert Sypolt of Terra Alta. 

Stanley is the son of Mr. and Mrs. Albert L. 
Stanley of Fayetteville. He earned a B. S. de- 
gree in biology in December, 1982. from West 
Virginia Wesleyan. 

The new awards bring to 68 the number of 
scholarships granted by the Medical Associa- 
tion since its program began in 1958. One 
scholarship was granted annually until 1962, 




A 

Debra Sue Hinzman 


William M. Skeens 



Susan Marie Sypolt John L. Stanley 


when the number was increased to two. In 1974, 
the Association began awarding four scholarships 
annually. 

Financial need is the major factor considered 
by the Committee on Medical Scholarships. 
Under provisions of agreements they sign, 
scholarship recipients must agree to practice in 
West Virginia for four years following gradua- 
tion and completion of postgraduate training 
and military obligations. 

Over the years, about 75 per cent of the 
scholarship recipients who have completed their 
training have entered practice in West Virginia, 
a result in line with the program objective en- 
couraging additional young physicians to estab- 
lish careers here. 

Other members of the Committee on Medical 
Scholarships are Drs. R. L. Chamberlain of 
Buckhannon, Marshall J. Carper of South 
Charleston. Robert D. Hess of Clarksburg, 
Thomas J. Holbrook of Huntington, James T. 
Hughes of Ripley, Kenneth G. MacDonald. Sr., 
of Charleston. William L. Mossburg of Fairmont, 
an earlier scholarship recipient, and David Z. 
Morgan of Morgantown. 


Scholars Program Recipient 

Dr. Eric Sawitz of the Marshall University 
School of Medicine is one of 20 physicians 
chosen this year for the Robert Wood Johnson 
Foundation Clinical Scholars Program. The 
program began July 1. 

He will spend two years studying health com- 
munications and medical computing at Stanford 
University and the University of California at 
San Francisco. He will receive a complete 
scholarship plus a stipend for his study and re- 
search. 


July, 1983, Vol. 79, No. 7 


157 



Results In Radial Keratotomy 
Study Reported Good 

A first prospective evaluation of radial kera- 
totomy reports good short-term results for the 
new operative procedure aimed at correcting 
myopia. 

Radial keratotomy is a surgical procedure in 
which a series of incisions is made in the cornea 
from the outer edge toward the center in spoke- 
like fashion. It is done to correct an error of 
refraction that causes rays of light entering the 
eye to be brought to a focus in front of instead 
of on the retina. 

"Although the predictability of radial kera- 
totomy is controversial, this study has shown that 
radial keratotomy can be effective for reducing 
myopia over a range of approximately 10 di- 
opters,” report Peter N. Arrowsmith. M. D.. of 
Nashville’s Parkside Surgery Center, and col- 
leagues in a recent issue of Archives of Ophthal- 
mology. 

Caution in U. S. 

The researchers point out that ophthalmolo- 
gists have been cautious in judging the safety and 
efficacy of radial keratotomy since its introduc- 
tion in the United States in 1978. Opinions about 
the procedure have ranged from mild endorse- 
ment to confidence about its effectiveness in re- 
ducing myopia and in its predictability. 

"We report the results of one carefully per- 
formed and monitored prospective evaluation of 
radial keratotomy,” the researchers say. “The 
emphasis of this report is on short-term efficacy 
and safety.” 

The study was conducted consecutively on 
156 eyes of 101 patients. Before surgery, mean 
spherical equivalent was -5.0 diopters, and un- 
corrected distance acuity was 20/200 or worse 
in 96 per cent of the eyes. 

Six-Month Results 

Six months after surgery, distance acuity was 
20/20 in 43 per cent and 20/40 or better in 73 
per cent of the eyes. The mean change in 
spherical equivalent was +4.8 diopters. 

“Visual acuity and refractive results were best 
for eyes in which preoperative myopia was less 
than 3.0 diopters, the researchers say. “In these 
eyes, 92 per cent achieved 20/40 or better un- 
corrected distance acuity six months after sur- 
gery, and 61 per cent had 20/20 acuity or bet- 
ter.” 


Medical Meetings 


July 31-Aug. 4 — National Spinal Cord Injury Assoc., 
Chicago. 

Aug. 1-3 — International Society for Sexually Trans- 
mitted Disease Research, Seattle. 

Aug. 1-5 — -Am. Venereal Disease. Seattle. 

Aug. 22-24 — Spinal Cord Regeneration & Recent De- 
velopments (Am. Paraplegia Society), Las 
Vegas. 

Aug. 25-27 — 116th Annual Meeting, W. Va. State 
Medical Assn., White Sulphur Springs. 

Sept. 7-10 — Peripheral Vascular Disease Symposium 
(Saint Anthony Hospital), Columbus, OH. 

Sept. 29-Oct. 1 — Am. Assoc, for the Surgery of 
Trauma. 

Sept. 29-Oct. 2 — Am. Society of Internal Medicine, 
San Francisco. 

Oct. 2-5 — Am. Neurological Assoc., New Orleans. 

Oct. 5-8 — Am. Thyroid Assoc., New Orleans. 

Oct. 7-8 — AMA Congress on Occupational Health, 
Beachwood, OH. 

Oct. 16-21 — Am. College of Surgeons, Atlanta. 

Oct. 22-27 — Am. Academy of Pediatrics, San Fran- 
cisco. 

Oct. 23-26 — Am. College of Gastroenterology, Los 
Angeles. 

Oct. 23-27 — Am. College of Chest Physicians, 
Chicago. 

Oct. 24-27 — Am. College of Emergency Physicians, 
Atlanta. 

Oct. 26-30 — Am. Academy of Child Psychiatry, San 
Francisco. 

Nov. 6-9 — Scientific Assembly, Southern Medical 
Assoc., Baltimore. 

Nov. 7-9 — Am. Medical Women’s Assoc., Dearborn, 
MI. 

Nov. 18-22 — Gerontological Society of Am., San 
Francisco. 

Nov. 30-Dec. 1 — Am. College of Chemosurgery, 
Chicago. 

1984 

Jan. 27-29 — 17th Mid-Winter Clinical Conference, 
Charleston. 

March 17 — Annual Meeting, W. Va. Affiliate, 

American Diabetes Assoc., Wheeling. 


158 


The West Virginia Medical Journal 



WHY BMW CHOSE 

TO CHANGE THE 
“QUINTESSENTIAL 

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The Bavarian Motor Works does not annually reinvent the automobile. In- 
stead they periodically refine it. 

So after six years the sedan Car and Driver nominated “the quintessential 
sports sedan”— the BMW 320i— has evolved into a new car: the 318i. A 
machine with a totally redesigned, fully independent suspension system, new 
aerodynamics, new technology, and a new fuel injection system that^^ 
delivers even greater torque. 

The result is not only a new car, but an apparent logical impossi- 
bility. “The quintessential sports sedan” is even more quintessential. 

Contact us for an exhilarating test drive. THE ULTIMATE DRIVING MACHINE. 

© 1983 BMW of North America, Inc, The BMW trademark and logo are registered- 



Harvey Shreve, Inc. 

ROUTE 60, WEST ST. ALBANS 722-4900 



WVU Medical Center 
-News- 



Compiled from material furnished by the Medical Center 
News Service, Morgantown , W. Va. 


H ow Should You Diagnose, Treat 
Borderline Hypertension? 

There is some disagreement among doctors 
concerning just what constitutes mild elevation 
of blood pressure and how it should be treated. 

“The controversy comes from the fact that we 
don't really know where the fine dividing line 
between normal blood pressure and hypertension 
is,” said Dr. Stanley R. Shane, Professor and 
Interim Chairman of Medicine. 

The most important issue, lie continued, in 
determining whether to treat borderline hyper- 
tension is the presence or absence of other risk 
factors — primarily family history of high blood 
pressure, obesity, diabetes and abnormal blood 
cholesterol or triglyceride values. Smoking and 
a sedentary lifestyle along with high stress or 
driving-type personality are believed to contrib- 
ute to elevated pressures, particularly when com- 
bined with the other risks. 

Related to Body Weight 

“Blood pressure is distinctly related to body 
weight,” he stated. “We don't understand why. 
There’s a fair amount of data that’s been looked 
at with no clear-cut relationship. But often if 
people reduce their weight, sometimes by just 10 
pounds, their blood pressure will be lowered and 
they can avoid medication. 

Doctor Shane said be believed physicians 
might justify not treating patients with border- 
line pressure elevations and no other risk factors 
with the realization that the actual average pres- 
sure is probably lower than that. 

“But on the other hand, that says a great deal 
about the role of stress," he explained. “If a per- 
son’s blood pressure rises because of a visit to the 
doctor, is there a similar response to other stress- 
ful situations? 

“I've seen patients who are on a sackfull of 
medicine — and their blood pressure is still not 
well controlled- -who will decide to leave a 
job they’ve found stressful for years. It's striking 

xvi 


to see their blood pressure return to normal. In 
fact, often I have to discontinue some of the 
medication.” 

Early treatment, in most cases of borderline or 
moderate hypertension should include stress 
management, weight control and salt restriction. 
Doctor Shane said. Also needed is development 
of a good health maintenance program with 
exercise. 

These instructions are seemingly easier for the 
physician to give than for the patient to follow, 
in many cases. 

Patient Compliance Difficult 

“Part of patient compliance is a matter of 
education. Doctor Shane said. “It's very diffi- 
cult dealing with hypertension because hyper- 
tension doesn’t cause pain or discomfort. If 
hypertension were associated with pain, you'd 
have no problem with compliance. 

“You always have to speak to patients in terms 
of future benefits — not today, not even tomor- 
row, but sometimes as much as 10-20 years down 
the road. Hypertension has its effects over the 
long term. It’s not an immediate thing, so it’s 
always difficult to talk to a patient about follow- 
ing a program or taking medication to prevent 
something that's going to happen 20 years from 
now.” 


Dr. Ludwig Gutmann Elected 
Neurologists’ Officer 

Dr. Ludwig Gutmann, Chairman of the De- 
partment of Neurology, has been named Presi- 
dent Elect of the Association of University Pro- 
fessors of Neurology. 

Doctor Gutmann has been Secretary-Treasurer 
for the past four years. Association membership 
includes all chairmen of departments of neu- 
rology in the United States. 

Doctor Gutmann, who has headed the WVU 
Neurology Department since 1970, is a gradu- 
ate of Princeton University, and received his 
medical degree from Columbia University. He 
was named to the National Board of Medical 
Examiners last, fall. 

The West Virginia Medical Journal 


HIGHLAND HOSPITAL 

56TH & NOYES AVE., S.E. 
CHARLESTON, W. VA. 25304 
925-4756 


MEDICAL STAFF 


ADULT PSYCHIATRY 


Miroslav Kovacevich, M. D. 

925-0693 

Charles C. Weise, M. D. 

925-2159 

Thomas S. Knapp, M. D. 

925-3554 

Pablo M. Pauig, M. D. 

343-8843 

Ralph S. Smith, M. D. 

925-0349 

Lee L. Neilan, M. D. 

925-0349 

Edmund C. Settle, Jr., M. D. 

925-6914 

Gina Puzzuoli, M. D. 

925-6914 

John P. MacCallum, M. D. 

925-6966 

CHILD PSYCHIATRY 

Henrietta L. Marquis, M. D. 

925-3160 

Pablo M. Pauig, M. D. 

343-8843 

Ralph S Smith, M. D. 

925-0349 

John P. MacCallum, M. D. 

925-6966 


Psychiatric treatment for the emotionally 
disturbed children ages 5 to 13 now avail- 
able in new children's pavilion. Separation 
maintained from adult psychiatric care 
unit. Each program offers: 

• Crisis Intervention 

• Group Therapy 

• Psychotherapy 

• Activities & Recreational Therapies 

• Skilled Attention to Family, Marital, and 
Individual Emotional Problems 

• Special Care for the Acutely Disturbed 
Patient 

• Staffed by Qualified Psychiatrists and 
Medical Consultants 

• Schooling Provided on Children’s Pa- 
vilion 

• Serving the Community for Over 25 
Years 


GOLDEN MEDICAL GROUP 

1200 Harrison Avenue 

ELKINS, WEST VIRGINIA 


ANESTHESIOLOGY: 

Y. H. Chung, M. D. 

COMMUNITY MEDICINE: 

R. C. Gow, M. D. 
(Thomas Clinic) 

S. O. Chung, M. D. 

M. C. Rosenberg, D. O 
(Helvetia Clinic) 

EMERGENCY MEDICINE: 

R. H. Plummer, D. O. 
A. M. Fuller, M. D. 

F. A. Khan, M. D. 

D. J. Lloyd, M. D. 

FAMILY PRACTICE: 

L. H. Valliant, M. D. 

C. S. High, M. D. 


INTERNAL MEDICINE: 
Gastroenterology: 

S. S. Masilamani, M. D. 

Allergy & Rheumatology: 

J. B. Magee, M. D. 

Cardiology: 

H. L. Jellinek, M. D. 

R. B. Garrett, M. D. 

Metabolic & Endocrine Diseases: 

F. Becerra, M. D. 

Pulmonary Diseases: 

J. C. Arnett, Jr., M. D. 

OBSTETRICS & GYNECOLOGY: 

H. H. Cook, Jr., M. D. 

J. F. de Courten, M. D. 

J. J. Rizzo, M. D. 

M. W. Strider, M. D. 

OPHTHALMOLOGY: 

J. N. Black, M. D. 

ORTHOPAEDIC SURGERY: 

J. G. Gomez, M. D. 


OTOLARYNGOLOGY 
(Facial Plastic and 
Reconstructive Surgery): 

J. A. Wolfe, M. D. 

PATHOLOGY: 

M. M. Stump, M. D. 
PEDIATRICS: 

Y. J. Kwon, M. D. 

R. J. Haas, M. D. 
PSYCHIATRY: 

R. W. O'Donnell, M. D. 
RADIOLOGY: 

F. H. Abdalla, M. D. 

H. Y. Mang, M. D. 

C. P. O’Sullivan, M. D. 
SURGERY: 

General, Thoracic & Vascular: 

J. A. Noronha, M. D. 

W. B. Blum, M. D. 

B. R. Blackburn, M. D. 

R. A. Rose, M. D. 

UROLOGY: 

D. T. Chua, M. D. 


July, 1983, Vol. 79, No. 7 


xvn 


Third-Party News, Views 
and Program Concerns 



Workers’ Compensation Fee 
Schedule Planned 

Workers’ Compensation Commissioner Gret- 
chen 0. Lewis lias advised medical providers 
that the Workers’ Compensation Fund is in the 
process of developing a medical fee schedule and 
updating its computerized claim system. 

A provision of state statute stipulates that 
“the commissioner shall establish, and alter from 
time to time as he ( or she) may determine to be 
appropriate, a schedule of the maximum reason- 
able amounts to be paid to physicians, surgeons, 
hospitals or other persons, firms or corporations 
for the rendering of treatment to injured em- 
ployees . . . 

In her letter to providers, Ms. Lewis had these 
other comments: 

“To insure prompt and correct payment to the 
providers and to permit our monitoring of the 
services rendered, we find it necessary to re- 
quire the proper CPT Code, in addition to a 
narrative description of the treatment rendered, 
when submitting fee bills to this office. 

“This has been a requirement for some time, 
hut has not been strictly enforced. However, 
effective July 1, 1983, we will no longer accept 
any fee hills without the proper CPT Codes. 

“Current Procedural Terminology (Fourth Edi- 
tion I code hooks may he purchased from ‘Order 
Department OP-041, American Medical Asso- 
ciation. P.0. Box 10946, Chicago. IL 60610 .” 
These CPT Code Books are presently available at 
the cost of $23.45 each, including postage and 
handling.” 


‘Squeal Rule’ Still Wanted 
By Administration 

Early this year, judges in both Washington 
and New \ ork blocked the controversial “squeal 
rule” which requires federally-funded family 
planning clinics to notify parents when their 
teenagers receive prescription contraceptives. 
But, in May the Reagan Administration went 

xviii 


back to the Washington, D.C., Appeals Court to 
urge reinstatement of the rule. 

Government appeal of the second suit, filed by 
New York State’s Attorney General, was sent to 
be heard in New York in June, the American 
Medical Association reported. 

Action Postponed in West Virginia 

In West Virginia, an Appeals Court postponed 
action on a third suit after the Washington and 
New York rulings. 

In Utah, a federal judge has blocked a state 
“squeal rule” until a full hearing is held. 

Attorneys for the Administration say that a 
1981 amendment passed by Congress was de- 
signed to make parents more involved in their 
children’s sexual decision-making. Simply en- 
couraging teenagers to talk to their parents has 
not helped reduce the number of teenage preg- 
nancies, they say. 

“It is absolutely clear that the Secretary of 
Health and Human Services had the authority to 
issue the regulations challenged in this case,” 
argued Justice Department lawyer Carolyn B. 
Kuhl before the Washington, D.C., judge. “The 
family cannot participate in an activity that it 
does not know is taking place ...” 

But family planning groups charge that the 
“squeal rule” invades a teenager’s right to pri- 
vacy and violates patient-physician confiden- 
tiality. Furthermore, there is little basis for the 
government’s contention that notification would 
protect the health of teenagers; prescription con- 
traceptives pose few problems to women under 
age 18, they say. 

AMA Against ‘Squeal Rule’ 

The AMA and the American College of Ob- 
stetricians and Gynecologists, siding with the 
family planning groups, contend that a notifica- 
tion rule will scare teenagers away from family 
planning clinics and lead to an upsurge in ado- 
lescent pregnancies. “Teens are five times more 
likely to die from pregnancy and childbirth than 
from the use of oral contraceptives,” Dr. Luella 
Klein, ACOG’s Vice President, said at a press 
conference earlier this year. 

The West Virginia Medical Journal 


Obituaries 


V. R. ANUMOLU, M. D. 

Dr. V. R. Anumolu, Fairmont internist, died 
on May 31 when fire burned the Myrtle Beach. 
Soutli Carolina, beachhouse in which he was 
sleeping. He was 37. 

Doctor Anumolu’s wife, Sarojini Anumolu. 
also died in the fire. 

Doctor Anumolu was a former member of the 
West Virginia State Medical Association. 

A native of India, he had practiced in Fair- 
mont for approximately seven years. 

* * * 

SAM MILCHIN. M. D. 

Dr. Sam Milchin, retired Bluefield general 
practitioner, died on May 31 at his home. He 
was 72. 

A native of Richmond. Virginia. Doctor Mil- 
chin was graduated from the University of Rich- 
mond, and received his M. D. degree in 1935 
from the Medical College of V irginia. 

He began practice in Bishop, Virginia, and 
Jenkinjones. West Virginia, moving to Bluefield 
in 1953. He then opened his office in Bluefield. 
Virginia. Residents of both Bluefields and the 
surrounding areas were among his patients. 

Upon his recent retirement, the community 
honored him with a dinner tribute. 

Doctor Milchin was a World War II Navy 
veteran. 

He was a member of the Mercer County 
Medical Society, West Virginia State Medical 
Association and American Medical Association. 

Surviving are the widow and two daughters, 
Mrs. Tom Garrett and Susan Milchin. both of 
Richmond. 


OPENING FOR 
CARDIOLOGIST 

INVASIVE CARDIOLOGIST, hospital 
rounds duties and some diagnostic testing. 
Mid-Atlantic states area. Abilities to do 
streptokinase and/or angioplasty desir- 
able. Salary and bonus. Respond with C-V 
to Box PAL, c/o The West Virginia Medical 
Journal, P. O. Box 1031, Charleston, WV 
25324. 


County Societies 


CENTRAL WEST VIRGINIA 

Dr. Frederick C. Whittier of Morgantown was 
the guest speaker for the spring meeting of the 
Central West Virginia Medical Society on May 5 
in Jacksons Mill at the Deerfield Country Club. 

Doctor Whittier. Chairman of the Department 
of Nephrology, West Virginia University Medical 
Center, discussed hypertension and nephrology. 

The Society approved two scholarships of $225 
each to Camp Kno-Koma, and a sustaining do- 
nation of $50 to the American Medical Associa- 
tion’s Medical Student Section. — Greenbrier Al- 
mond, M. D., Secretary-Treasurer. 

* # * 

WESTERN 

The Western Medical Society met on May 10 
in Ripley at the McCoys Motor Lodge. 

The host for the evening was The John Han- 
cock Insurance Company, whose representative, 
Tom Leadbetter, was the guest speaker. His 
topic was “Personal Financial Planning.” 

The Society will adjourn for the summer, with 
the next meeting scheduled on September 13 at 
Roane General Hospital in Spencer. — -Ali H. 
Morad. M. D., Secretary-Treasurer. 

* # * 

PARKERSBURG ACADEMY 

The Parkersburg Academy of Medicine met on 
March 9 at the Parkersburg Country Club. 

The guest speaker was Robert McHenry, Trust 
Officer of Parkersburg National Bank, whose 
topic was “Estate Planning, Wills and Trust.” 

The Academy met again on April 13 at the 
Parkersburg Country Club. Robert Shade, M. D., 
Associate Professor of Medicine, Division of 
Gastroenterology, University of Pittsburgh, was 
the guest speaker. His subject was “Peptic 
Ulcer Disease-GI Bleeding.” 

The Academy approved a donation of $225 
for Camp Kno-Koma. 

The Academy met again on May 11 at the 
Parkersburg Country Club. The guest speaker 
was Don Sensabaugh, an attorney with the 
Charleston firm of Kay, Casto and Chaney, whose 
topic was “Medical Malpractice.” 

( continued on page xxiii ) 


July, 1983, Vol. 79, No. 7 


xix 




Professional 

Liability Insurance 
Designed for 
West Virginia 
Physicians 

“The Association recommends 
its endorsed program to you for... 
your most considered review and 
attention.” 

Reprinted from The West Virginia Medical Journal, September 1981 



Your Association’s Professional Liability Insurance Program Includes: 


• A market guarantee with Continental Casualty Company, 

CNA, the fourth-largest underwriter of professional liability 
insurance in the United States. 

• A consent to settle provision for doctors covered under the plan. 

• An in-state managing general agent, McDonough Caperton Shepherd 
Group, with offices located in five key West Virginia cities 

to provide risk management and technical expertise in professional 
liability matters. 

• A payment plan with no finance charges. 

• A profit-sharing mechanism. 

McDonough 

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Group 

Uniquely capable... Professionally competent 



Corporate Headquarters: One Hillcrest Drive, East, P O Box 1551, Charleston, WV 25326. Telephone: (304) 346-0611 
With offices in Beckley, Charleston, Fairmont, Parkersburg, Wheeling 


The West Virginia Medical Journal 


Vol. 79, No. 8 


August, 1983 



Effect of Ethrane Supplementation On Intrapulmonary 

Shunting In Dogs 

Anesthetized With Nitrous Oxide And Morphine 


DAVID F. GRAF, M. D. 

Associate Professor of Anesthesiology, West Virginia 
University School of Medicine, Morgantown 

LAWRENCE M. LAVINE, M. D. 

Assistant Professor of Anesthesiology, 

University of Chicago School of Medicine, 

Chicago, Illinois 


This study involving eight mongrel dogs was 
undertaken to determine whether pulmonary 
oxygenation is adversely affected by the supple- 
mentation of enflurane to nitrous narcotic 
anesthesia under normal states of cardiovascular 
and respiratory function. 

The results indicate that under normal states 
of respiratory and cardiovascular function , sup- 
plementation of enflurane to morphine-N^O-O-z 
anesthesia in response to painful stimuli has no 
adverse effect on pulmonary oxygenation. 

Intrapulmonary shunting and arterial pO 2 were 
unchanged from baseline values ( p>.05) except 
at 45 minutes when intrapulmonary shunting was 
actually decreased (p<.05). 

eneral anesthesia, by producing decreased 
FRC. increased small airway closure, micro- 
atelectasis and altered ventilation/perfusion 
ratios, causes regional alveolar hypoxia. This 
regional alveolar hypoxia is partially compen- 
sated by pulmonary hypoxic vasoconstriction, 
which redistributes blood flow from hypoxic 
alveoli to normoxic alveoli. 1 Since the first 
description of this phenomenon, 2 numerous 
studies have been performed in man and animals 
determining that hypoxic pulmonary vasocon- 
striction is relatively spared by narcotics and 


nitrous oxide, but may he inhibited by halothane 
or enflurane. 3 ' 4,5,6,/ 

To insure adequate pulmonary oxygenation, 
some anesthesiologists routinely increase the 
FiOi> of inspired gases when they supplement 
nitrous-narcotic anesthesia with enflurane. The 
purpose of this study was to determine whether 
this practice is really necessary. 

Eight mongrel dogs, weighing 18-22 kg., were 
given an infusion of four ml/kg of D5RL, and 
then were infused with four ml/kg/hour of 
D5RL during the experiment. The dogs were 
anesthetized with four mg/kg sodium pentothal, 
given one mg/kg succinylcholine and intubated 
with a cuffed endotracheal tube. Anesthesia was 
maintained with 66 per cent NiO, 33 per cent 
0i>, and one half mg/kg morphine sulfate. The 
dogs were given 0.4 mg/kg curare and mechani- 
cally ventilated maintaining a pCOi- of 35-40 
torr. An arterial line and a Swan Ganz catheter 
were introduced. Blood pressure and heart rate 
were continuously monitored. 

Baseline Data 

One hour after induction of anesthesia, the 
following baseline data were obtained: systemic 
arterial pressure, arterial blood gas, mixed 
venous PO;;, cardiac output (via thermodilution 
method), and heart rate. Blood removed for 
sampling was immediately replaced with an 
equal volume of D5RL. After baseline data 
were obtained, the tails of the dogs were 
clamped. In response to this stimulus, enflurane 
was administered to maintain the mean arterial 
pressure at 80 per cent of its preclamping value. 


August, 1983, Vol. 79, No. 8 


159 


Additional sets of data were collected five 
minutes, 15 minutes, and 45 minutes after tail- 
clamping. 

The intrapulmonary shunt was calculated from 
the following equation: 

shunt — Cc’ - Ca 
Cc’ - Cv 

Cc’ is the oxygen content in the pulmonary 
end-capillary blood. 

Ca is the oxygen content of arterial blood. 

Cv is the oxygen content of mixed venous 
blood. 

Cc’ is calculated from tbe “ideal” alveolar 
Po:> (itself calculated from tbe Alveolar Air 
Equation ), the hemoglobin content of the blood, 
and tbe relationship between P0_> and saturation 
of hemoglobin (tbe oxygen dissociation curve). 

Data Compared 

The data obtained for each time interval were 
compared with the corresponding pre-clamping 
values by use of the paired T-test. As expected, 
the mean values of the arterial pH, pCCE, 
cardiac output, and heart rate were unchanged 
from their control values for all time periods 
(p>0.05). Mean arterial pressure was approxi- 
mately 80 per cent of its control value for all 
time periods. 

Of significance were the results obtained for 
the arterial pCC and tbe intrapulmonary shunt. 
The mean arterial pCE was unchanged for all 


time periods (p>0.05). The intrapulmonary 
shunt was unchanged from its control value in 
40 per cent of the dogs, and was decreased by 
50 per cent of its baseline value in the other 
60 per cent of the dogs. Overall, the average 
intrapulmonary shunt was slightly decreased at 
the five- and 15-minute time intervals, and was 
significantly reduced at the 45-minute time inter- 
val (p<0.05). 

In conclusion, it appears that under normal 
states of respiratory and cardiovascular function, 
supplementation of enflurane to morphine- 
N-O-CE anesthesia in response to painful stimuli 
has no adverse effect on pulmonary oxygenation. 

References 

1. Fishman AP: Respiratory gases in the regulation of 
pulmonary circulation. Physiol 1961; 41:214-280. 

2. Beyhe J : Influence de panoxemie sur la grande 

circulation et sur la circulation pulmonaire. Compt Rend 
Soc Biol 1942; 136:399-400. 

3. Sykes MK et al .: Preservation of the pulmonary 
vasoconstrictor response to alveolar hypoxia during the 
administration of halothane to dogs. Br J Anaesth 1978; 
50:1185-1196. 

4. Bjertnaes LJ et al.: Hypoxic pulmonary vasocon- 
striction: Inhibition due to anesthesia. Acta Physiol 

Scand 1976; 96:283-285. 

5. Mathers J et al.: General anesthetics and regional 
hypoxic pulmonary vasoconstriction. Anesthesiology 1977 ; 
46:111-114. 

6. Price HL et al.: Pulmonary hemodynamics during 
general anesthesia in man. Anesthesiology 1969; 30:629- 
636. 

7. Gibbs JM, Johnson H: Lack of effect of morphine 
and buprenorphine on hypoxic pulmonary vasoconstriction 
in the isolated, perfused cat lung and the perfused lobe 
of the dog lung. Br J Anaesth 1978; 50:1197-1199. 


160 


The West Virginia Medical Journal 


Dopamine-Modulating Drugs, Amenorrhea-Galactorrhea 
And Neuropsychiatric Illnesses 


PAUL E. FRYE, M. D. 

Fairmont, West Virginia; Clinical Assistant Professor 
of Behavioral Medicine and Psychiatry, West Virginia 
University School of Medicine, Morgantown 


The properties and clinical uses of drugs that 
alter dopamine function in the brain are 
discussed in relationship to hypotheses in 
psychoneuroendocrinology. Established and po- 
tential treatments in the three related medical 
disciplines are discussed. The role of dopamine 
and its receptors in psychiatric illnesses, move- 
ment disorders, and amenorrhea-galactorrhea is 
emphasized. Treatment in one area may result 
in altered function in other systems in which 
dopamine has a role. 

-pVRUGS that facilitate or inhibit dopaminergic 
transmission in the central nervous system 
( CNS ) are used in many areas of medicine. 
Modifying the activity of dopaminergic systems 
in the CNS has psychiatric, neurologic and en- 
docrinologic effects. The purpose of this paper 
is to discuss the drugs, the hypotheses, and the 
clinical aspects of dopamine modulation. 

Phenothiazines, such as chlorpromazine 
(Thorazine), were introduced in this country 
as antipsychotics three decades ago; sub- 
sequently, physicians have used effectively a 
number of neuroleptic compounds in the treat- 
ment of schizophrenia and affective disorders. 
Amphetamines and other CNS stimulants have 
been used as antidepressants and anorexic 
agents. They are presently accepted treatment 
for narcolepsy and attention deficit disorders. 

The usefulness of levodopa (Sinemet) in 
Parkinsonism was followed by the discovery of 
additional anti-Parkinson agents among the ergot 
alkaloids. These compounds have a structural 
similarity to dopamine. 1 Chemical modification 
has produced related compounds with less 
vasoconstrictor and uterine effects, than are com- 
mon in the naturally-occurring ergot alkaloids. 
These derivatives include bromocriptine, which 
retains the property of dopamine facilitation and 
the ability to inhibit prolactin secretion. Ameri- 
can clinicians recently have begun using bromo- 
criptine mesylate (Parlodel) to treat hyper- 
prolactinemia. 2 In Europe, bromocriptine has 
found application in a variety of endocrine dis- 
orders, including acromegaly.' 1 


Pharmacologic properties of the opiate 
alkaloid apomorphine, including its potency for 
inducing emesis, have precluded its use in 
Parkinsonism, but it has been an important 
compound in research in the pharmacology of 
dopaminergic systems. Apomorphine is pre- 
sumed to be a “direct’’ stimulator of dopamine 
receptors, because its effects are not altered by 
drugs that inhibit the production or storage of 
intrinsic dopamine. 4 (Thus it is appropriately 
called a dopamine agonist, while amphetamines 
and other compounds that facilitate transmission 
via intrinsic dopamine are not.) 

Hypotheses in Psychiatry, Neurology, 
and Endocrinology 

Dopamine is released into synapses in the 
nigrostriatal. mesolimbic, and tuberoinfundibu- 
lar (or tuberohypophyseal ) systems. It has 
various effects as a result of interaction with 
post-synaptic receptors, and also acts in direct 
inhibitory feedback by way of autoreceptors on 
the cell of origin. Dopamine-modulating drugs 
vary in their direct or indirect effects on pre- 
synaptic and postsynaptic receptor activity. 
Whether the presynaptic (inhibitory) effect will 
predominate is believed to depend on concentra- 
tion for some drugs. For example, low doses of 
apomorphine result in predominantly presynaptic 
activity and. thus, an inhibitory influence (in 
contrast to its property of dopamine agonism at 
higher doses ) . 4,-> ' 6 Biochemical findings that 
implied increased turnover of dopamine during 
neuroleptic treatment led Carlsson and Lindqvist 
to speculate, in 1963, that the mode of action 
of antipsychotic drugs is blockade of dopamine 
receptors. 

Additional data subsequently have supported 
and modified a “dopamine hypothesis’’ for the 
etiology of schizophrenia. 8 The hypothesis is 
that schizophrenia is a result of excessive activity 
of dopaminergic neural systems. Previously well 
patients occasionally develop neuropsychiatric 
syndromes as a result of toxic effects of ingested 
substances. Drugs known to facilitate dopamine 
have been associated with psychiatric syndromes 
resembling schizophrenia or affective disorder. 
Paranoid ideation, delusions, hallucinations, 
inappropriate behavior, disorders of thinking, 
and affective disturbances have been documented 
following use of levodopa, amphetamine, co- 


August, 1983, Vol. 79, No. 8 


161 


caine, methylphenidate (Ritalin), bromocriptine, 
and lergotrile. 9,10 The occurrence of such 
syndromes in persons presumably without 
psychiatric illness gives impetus to the assump- 
tion that ingestion of these drugs would exacer- 
bate the illness of persons with schizophrenia, 
which by hypothesis means vulnerable dopami- 
nergic neural systems. Stimulants and ergot 
alkaloids do increase psychotic symptoms in 
some (but not all) schizophrenics. 8,11 This is 
compatible with the dopamine hypothesis of 
schizophrenia. 

Altered dopaminergic function also has been 
postulated in attempts to explain the etiology of 
affective disorders. Randrup and Braestrup 
interpret data and cite reviews supporting a 
dopamine hypothesis of depression. 12 Various 
authors have reported evidence of a dopami- 
nergic mechanism in mania. 12,13 

Parkinsonism, Receptor Changes 

The association of degeneration of dopami- 
nergic systems in the substantia nigra with 
Parkinsonism led to a search for a dopamine 
precursor. 8 The success of levodopa in treat- 
ment of this crippling illness and the mimicking 
of Parkinson’s disease as an adverse effect of 
neuroleptics that are potent dopamine antag- 
onists support the assumption of decreased 
dopaminergic function in the etiology of Parkin- 
sonism. 

Prolonged alterations of neurotransmitter 
function result in receptor changes. Tardive 
dyskinesia involves rhythmic, involuntary move- 
ments of the orofacial, limb or trunk muscles, 
and it is associated with neuroleptic treatment. 14 
In order to explain the occurrence of tardive 
dyskinesia during or following neuroleptic drug 
use, an increased sensitivity, similar to the type 
seen following denervation, has been postulated 
to occur in central dopamine receptors. 1 ’ In 
th is model, prolonged blockade of receptors 
leads to supersensitivity; withdrawal of the 
blocking agent is followed hy a rebound effect 
of greater transmission than normal. Bunney 
et al. reviewed evidence suggesting that lithium 
can block or modify the development of super- 
sensitivity in CNS dopamine receptors. 16 

A number of physiologic and non-physiologic 
processes can elevate prolactin levels and produce 
amenorrhea and galactorrhea. Dopamine-modu- 
lating drugs have pronounced effects on pro- 
lactin: antagonism of dopamine results in hyper- 
prolactinemia, while dopamine agonists lower 
prolactin levels. 2 Primary control of prolactin 
secretion is hy tuberoinfundibular dopaminergic 
neurons that terminate at the hypophyseal portal 


system; regulation occurs by release of a pro- 
lactin-inhibitory factor that is probably dopa- 
mine itself. 3 

Dopamine appears to provoke human growth 
hormone (HGH) release under normal condi- 
tions. Levodopa, apomorphine, and bromocrip- 
tine increase HGH secretion in normal persons; 
however, in patients with acromegaly, the same 
medications paradoxically decrease excessive 
growth hormone levels. Several authors have 
speculated on the role of dopamine in regulating 
HGH, but as yet no explanation for this 
phenomenon is fully satisfactory. 3 

Clinical Aspects of Dopamine Modulation 

The use of neuroleptics, stimulants, and anti- 
Parkinson agents to modify transmission in 
dopaminergic systems is well-established. Their 
adverse effects include toxic psychoses, drug- 
induced movement disorders, and amenorrhea- 
galactorrhea. Most physicians are skilled in early 
recognition and treatment of extrapyramidal 
reactions to neuroleptics. On the other hand, 
amenorrhea, galactorrhea, and adverse effects on 
sexuality generally have gone without emphasis. 
Screening for these troublesome and unintended 
results may reveal problems in as many as one 
woman in two, or one in 10 men. 1 ' 

Amenorrhea and galactorrhea have been as- 
sociated with neuroleptics since shortly after the 
introduction of the phenothiazines in the 
1950s. 18 For all neuroleptics of each chemical 
family, nearly all patients have elevation of 
plasma prolactin within three days. 17,19 Apostol- 
akis et al. reported a study of 260 patient^: 50 
per cent of females and 10 per cent of males, 
taking psychotropic drugs known to cause 
hyperprolactinemia, developed some degree of 
inappropriate lactation. 20 A higher than normal 
frequency of amenorrhea has been reported 
among patients with untreated psychiatric dis- 
orders. 18 As a result, it is difficult to conclude 
what proportion of amenorrhea during neuro- 
leptic treatment to attribute to drug effect. 
Nonetheless, elevated prolactin is clearly a major 
cause of amenorrhea, whether or not it is ac- 
companied by galactorrhea. 2 

Bromocriptine mesylate has been approved by 
the U. S. Food and Drug Administration for 
treatment of amenorrhea-galactorrhea of various 
etiologies, excluding demonstrable pituitary 
tumor; more recently, it was approved for post- 
partum inhibition of lactation. Conversely, 
experience with dopamine agonists for treatment 
of endocrine disorders is limited. Because we 
are unable to forecast which patients are at risk 
for exacerbation of psychiatric symptoms, it is 


162 


The West Virginia Medical Journal 


difficult to justify the use of bromocriptine or 
other dopamine agonists as the initial treatment 
for neuroleptic-induced amenorrhea-galactorrhea. 
( Alternatives with less risk are discussed below. ) 

When bromocriptine must be prescribed for 
patients with a history of schizophrenia or affec- 
tive disorder, low initial dosage and small in- 
crements thereafter are preferable in order to 
minimize psychiatric complications. Frequent 
assessment of mental status is critical. If 
neuropsychiatric disturbance does occur, it 
appears to be reversible, at least during the early 
stages of bromocriptine treatment. 21 The large 
number of physiologic and pathologic processes 
that can cause hyperprolactinemia mandates that 
all patients with amenorrhea-galactorrhea have a 
thorough evaluation prior to starting bromo- 
criptine. This includes endocrine studies and 
tomographic roentgenograms of the sella 
turcica. 22 

When a patient develops amenorrhea-galacto- 
rrhea during neuroleptic treatment and has no 
indication of another etiology, the physician has 
several options for an initial approach. Eleva- 
tion of prolactin by neuroleptics is dose-related 
and quickly reversible. 19 Thus, one choice is 
to lower the dose of neuroleptic. (Using the 
lowest effective dose also has been advocated to 
produce the least interference in cognitive func- 
tion and to reduce the risk of neuroleptic-in- 
duced (tardive) dyskinesia. 23 ) Another option 
is to change medications since each neuroleptic 
raises prolactin to a different degree. 19 

Psychiatric Applications 

Despite the importance of caution in clinical 
use of bromocriptine and other dopamine 
facilitators for patients with psychiatric illness, 
experimental uses of drugs that increase 
dopaminergic function suggest potential psychi- 
atric applications of this property. Bromo- 
criptine, apomorphine, and piribedil (all dopa- 
mine agonists ) have been reported useful in 
mania. 13 Recent cases have appeared in the 
literature reporting the use of methylphenidate 
in the treatment of depression among elderly 
patients for whom standard treatments were 
contraindicated. 24 

Steiner and Carroll reviewed the literature 
supporting the utility of bromocriptine in pre- 
menstrual dysphoria syndrome. 25 When Tam- 
minga et al. gave apomorphine in low doses to 
test the presynaptic dopamine inhibition hypo- 
thesis, nine of eighteen schizophrenic patients 
had 20- to 50-per cent reduction of symptoms 
(compared to placebo): some stopped halluci- 


nating; some lost their delusions. 6 Friedhoff 
reported success using levodopa to treat tardive 
dyskinesia; his hypothesis is that supersensitive 
dopamine receptors are “retuned” to lower 
sensitivity by brief overstimulation and resultant 
compensation. 15 

Conclusion 

Dopamine blockade has brought major ad- 
vances in psychiatric treatment. Other modifi- 
cations of dopaminergic transmission in the CNS 
are established treatment in neurology, psychi- 
atry, and endocrinology, or offer potential bene- 
fits on these frontiers. These advances have 
promoted new understanding of brain function; 
yet. the adverse effects of dopamine modulation 
remain. 

Psychiatrists will continue to utilize dopamine- 
blocking neuroleptics when indicated, until bet- 
ter treatment is found. It is important that pri- 
mary care physicians be aware that neuroleptic 
drugs are a common cause of amenorrhea and 
galactorrhea, and that treating with dopamine 
agonists carries risks that are not eliminated 
simply because the patient is in remission or is 
taking neuroleptic medication. 

When physicians evaluate patients with acute 
mental status changes, drug-induced facilitation 
of dopaminergic transmission must be included 
in the differential diagnosis. For example, a 
person with bromocriptine-induced organic de- 
lusional syndrome (toxic organic brain syn- 
drome ( must be differentiated from “schizoph- 
renic.” Early intervention may prevent the 
detrimental interpersonal, intrapsychic, bio- 
chemical, and social-vocational changes that can 
result from the internal events and external 
manifestations of psychosis or from stigmata 
that follow diagnostic labeling. Alertness to this 
distinction may avert unnecessary suffering. 

Editor s Note : Here are the generic drugs and 
trade names (in parentheses) to which reference 
is made in this manuscript : bromocriptine mesy- 
late (Parlodel) ; chlorpromazine (Thorazine); 
levodopa (Sinemet); and methylphenidate 
( Ritalin ). 

References 

1. Parkes D: Bromocriptine. N Engl J Med 1979; 
301:873-878. 

2. Frantz AG: Prolactin. N Engl J Med 1978; 298: 
201-207. 

3. Spark RF, Dicks tein G: Bromocriptine and endo- 
crine disorders. Ann Intern Med 1979; 90:949-956. 

4. Cooper JR, Bloom FE, Roth RH: Effect of drugs 
on the activity of dopaminergic neurons, in The Bio- 
chemical Basis of Neuropharmacology, New York, Oxford, 
1978, pp 183-186. 


August, 1983, Vol. 79, No. 8 


163 


5. Muller EE, Nistico G, Scapagnini U: Metabolism 
of dopamine, in Neurotransmitters and Anterior Pituitary 
Function, New York, Academic Press, 1977, pp 57-64. 

6. Tamminga CA, Schaffer Mil. Smith RC, Davis JM: 
Schizophrenic sysmptoms improve with apomorphine. 
Science 1978; 200:567-568. 

7. Snyder SH, Banerjee SP, Yamamura HI, Greensburg 
D: Drugs, neurotransmitters, and schizophrenia. Science 
1974; 184; 1243-1253. 

8. Snyder SH: The dopamine hypothesis of schizo- 
phrenia: Focus on the dopamine receptor. Am J Psy- 
chiatry 1976; 133:197-202. 

9. Klawans HL, Margolin DI: Amphetamine-induced 

dopaminergic hypersensitivity in guinea pigs: Implica- 

tions in psychosis and human movement disorders. Arch 
Gen Psychiatry 1975; 32:725-732. 

10. Serby M, Angrist B, Lieberman A: Mental dis- 

turbances dining bromocriptine and lergotrile treatment 
of Parkinson’s disease. Am J Psychiatry 1978; 135:1227- 
1229. 

11. Tamminga CA, Schaffer MH : Treatment of schizo- 
phrenia with ergot derivatives. Psychopharmacol 1979; 
66:239-242. 

12. Randrup A, Braestrup C: Uptake inhibition of 

biogenic amines by newer antidepressant drugs: Rel- 

evance to the dopamine hypothesis of depression. Psy- 
chopharmacol 1977; 53:309-314. 

13. Gerner RH, Post RM, Bunney WE: (letter) Dr. 
Gerner and associates reply. Am J Psychiatry 1977; 134: 
703. 

14. Ananth J : Tardive dyskinesia: Myths and realities. 
Psychosomatics 1980; 21:389-396. 

15. Friedhoff AJ : Receptor sensitivity modification 

(RSM)— a new paradigm for the potential treatment of 
some hormonal and transmitter disturbances. Comp 
Psychiatry 1977; 18:309-317. 


16. Bunney WE, Pert A, Rosenblatt J, Pert CB, Gal- 

laper D: Mode of action of lithium: Some biological 

considerations. Arch Gen Psychiatry 1979; 36:898-901. 

17. Dickey RP, Stone SC: Drugs that affect the breast 
and lactation. Clin Obstet Gynecol 1975; 18:95-111. 

18. Beumont PJV, Gelder MG, Friesen HG, Harris 
GW, Mackinnon PCB, Mandelbrote BM, Wiles DH: The 
effects of phenothiazines on endocrine function: I. Pa- 
tients with inappropriate lactation and amenorrhea. Br J 
Psychiatry 1974; 124:413-49. 

19. Meltzer HY, Fang VS: The effect of neuroleptics 
on serum prolactin in schizophrenic patients. Arch Gen 
Psychiatry 1976; 33:279-286. 

20. Apostolakis M, Kapetanakis S, Lazos G, Madena- 

Pyragaki A: Plasma prolactin activity in patients with 

galactorrhea after treatment with psychotropic drugs, in 
Wolstenholme GEW, Knight J (eds): Lactogenic Hor- 

mones. CIBA Found Symp, 1972, pp 349-351. 

21. Frye PE, Pariser SF, Kim MH, O’Shaughnessy 
RW: Bromocriptine associated with symptom exacerba- 
tion during neuroleptic treatment of schizoaffective 
schizopluenia. J Clin Psychiatry 1982; 43:252-253. 

22. Boyd AE, Reichlin S, Turksoy RN: Galactorrhea- 

amenorrhea syndrome: Diagnosis and therapy. Ann 

Intern Med 1977; 87:165-175. 

23. Hansell N: Approaching long-term neuroleptic 

treatment of schizopluenia. JAMA 1979; 242:1293-1294. 

24. Katon W, Raskind M: Treatment of depression 
in the medically ill elderly with methylphenidate. Am J 
Psychiatry 1980; 137:963-965. 

25. Steiner M, Carroll BJ: The psychobiology of 

premenstrual dysphoria: Review of theories and treat- 

ments. Psychoneuroendocrinology 1977; 2:321-335. 


Drug Prevents Hemorrhages In Injured Eye 

R esearchers at theUniversity of Illinois Eye and Ear Infirmary, Chicago, have dem- 
onstrated conclusively the safety and efficacy of a heretofore neglected treatment to 
prevent recurring hemorrhage in an injured eye. 

Their report in a recent issue of Archives of Ophthalmology shows that aminocaproic 
acid administered in precisely calculated doses can reduce significantly the incidence of 
secondary hemorrhage after blunt (nonperforating) trauma to the eye. The drug, 
a synthetic amino acid, works by inhibiting dissolution of blood clots and consequent 
reopening of ruptured ocular blood vessels, according to John J. McGetrick, M. D. 


164 


The West Virginia Medical Journal 


116th ANNUAL MEETING 



of the 

West Virginia State Medical Association 


ZJhe Green brier 


AUGUST 25-27, 1983 

PLAN NOW TD ATTEND 


August, 1983, Vol. 79, No. 8 


165 


c/l menage front . . . 


*jke president 


HANGING TOGETHER 


't'his is my last President’s Page. Dr. Carl Adkins 
of Fayetteville will be installed as your President 
at our Annual Meeting this month. While this has 
been a fantastic year and has meant more, personally 
and professionally, than I can express, I nonethe- 
less confess to some small sense of relief that I will 
be passing the gavel, especially to such a capable 
person. During the past year, I discussed in these 
pages issues that I felt were important to call to 
your attention, such as improving communication, 
involvement in the political process, cost contain- 
ment, malpractice tort reform, efforts in caring for 
the medically needy and the role of our organiza- 
tion. While I am sure that there have been some 
disagreements, I have been encouraged by the many 
positive comments I have heard. 

For my last message, I would like to address an 
issue that is, in my view, a potential cause for con- 
cern. I am concerned about the possibility of in- 
creasing fragmentation of our profession into 
smaller, limited-interest specialty groups. These 
groups sometimes seem to have a very narrow 
sphere of interest, and may not be as willing to take 
a broader view of what is best for our patients and 
for Medicine in general. 

As a urologist, I am well aware of the importance 
of the point of view of the specialist or subspecialist, 
but the broader view may be required in these times. 
Numerous outside pressures, such as governmental 
economic constraints, third-party payor intervention 
and the continuing malpractice crisis climate, are 
threatening the foundations of our free-enterprise, 
individual doctor-patient relationship, the basis for 
the best medical care in the world. We must not for- 
get that we are all doctors first, and specialists 
second. This is not a reflection of a “circle the 
wagons” mentality or in response to a perceived 
threat by any group. It is a realistic appraisal of 
problems potentially facing us. At a time when 
severe economic constraints are being imposed on 
health care by outside forces, we in Medicine — 
united — must continue to stand firm for what we 
believe in: quality — the best possible care for the 

patient at the lowest possible cost. If we fragment 


ourselves into smaller groups with conflicting in- 
terests, then we may lose some of the influence we 
can yield as a united group for the ultimate benefit 
of our patients. 

There is nothing wrong with differences of opinion 
and candid, blunt discussion. This is very crucial 
and needed, but if such discussion reaches the point 
of dissension and discord, and sets group against 
group or specialist against generalist, this serves 
neither the best interests of our patients nor of 
Medicine. There are legitimate differences of opinion 
and outlook among groups of specialists, and even 
groups of physicians within those specialties. The 
place to bring these different viewpoints together 
is through the framework of our State Medical 
Association and of the AMA. There, honest differ- 
ences of opinion can be aired, conflicting ideas re- 
solved and a consensus reached. There is no doubt 
that united we will have more influence for the 
benefit of our patients than many smaller groups 
can achieve. 

These are trying times for the profession of 
Medicine, and many changes are in sight. This is 
no time for “business as usual” or limited self- 
interest. We need innovative and imaginative ways 
to deal with these changes and to preserve the 
quality of care we have worked so hard to achieve. 
In the words of Ben Franklin from our historical 
past, “Gentlemen, we must all hang together, or 
most assuredly, we shall all hang separately.” 

I look forward to seeing you all at our Annual 
Meeting to air your views and opinions; to make 
your comments; to share your ideas, and finally, to 
participate in reaching a consensus which will be- 
come the policy for the West Virginia State Medical 
Association. See you at the Greenbrier! 





Harry Shannon, M. D., President 
West Virginia State Medical Association 


166 


The West Virginia Medical Journal 


The West Virginia Medical Journal 

Editorials 

The Publication Committee is not responsible for the authenticity of opinion or statements made by authors or 
in communications submitted to this Journal for publication. The author shall be held entirely responsible. 
Editorials printed in The Journal do not necessarily reflect the official position of the West Virginia State 
Medical Association. 


Physicians must communicate “among our- 
selves, with our patients, with the media and 
the Legislature," Harry Shannon, M. D., said 
a year ago in assuming the Presidency of the 
West Virginia State Medical Association. 

He set some other guidelines for his year in 
office, too. The public must be re-educated to 
the fact that the vast majority 
POSITIVE YEAR of physicians care first about 
their patients. The state must 
have a strong Board of Medicine because “if 
we intend to show the public we are as concerned 
about quality of care as indeed we are, then we 
must demonstrate that concern." 

Harry Shannon has carried those messages, 
and many more, into every corner of the state 
this past year — and has done so effectively. The 
media consistently has picked up his thoughts 
from the President’s Page in The Journal and 
further broadcast them to the reading, listening 
and viewing public. 

Have all his visions become reality? No, and 
that simply is an impossible thing to expect over 
the short period of 12 months. But Carl R. 
Adkins, M. D., is ready in the wings to pick 
up on most of these major themes, and build 
further on them, in his year ahead. 

The past couple of years have brought a new 
continuity in the office of President, with those 
who recently have served involved in detailed 
exchange of ideas and objectives with those 
coming up the Association’s leadership ladder. 
Never in the 116-year history of the organiza- 
tion has this been more important. 

Doctor Shannon clearly has learned many 
things as he has trudged from his practice in 
Parkersburg to Weirton in the north; McDowell, 
Mingo and Mercer counties in the south: Jeffer- 
son and Berkeley in the east, and Cabell and 
Mason to the west. 

He’s learned that there are physicians deeply 
interested in the Association, and what it’s trying 
to do. He’s encouraged more involvement of all 
physicians, and has particularly urged that they 


speak out about their concerns and their own 
goals and values. 

The more lines of communication “we can 
open." he said last August, “the easier it will be 
to resolve any differences and to achieve our goal 
of the highest quality of care for our patients in 
West Virginia.” 

What critical tasks still lie ahead? There are 
increasing numbers every year in this age of 
rapid technological advance, a growing physician 
population with eager young doctors with their 
own views and values — and the constantly 
broadening pressures upon Medicine and those 
it serves from the general arena of government 
and bureaucracy. 

Within the Association, communication needs 
much additional work. So do short and long- 



Harry Shannon, M. D. 


August, 1983, Vol. 79, No. 8 


167 



range planning; membership recruitment and 
services; more effective and sophisticated risk 
management programs, and a year-around 
approach to legislative affairs. 

The year has brought significant progress. 
Further tightening and development of accredi- 
tation for community hospital continuing medi- 
cal education programs have underlined the fact 
that West Virginia has one of the better such 
efforts anywhere. Work in the area of profes- 
sional liability insurance coverage has been in- 
tensified. 

Doctor Adkins, as is the case with each new 
President, will bring his own ideas and objectives 
into the picture, along with a commitment to 
those already in place. He will add some 
unique expertise in the field of business admini- 
stration and management, a commodity most 
significant in the light of current and prospective 
economic conditions. 

The Association has grown significantly with 
Doctor Shannon’s dedication and intense desire 
to serve its membership and the public of this 
state. Positions relative to quality care and the 
basic theme that the Association must exist first 
for the good of the patient have been strength- 
ened. 

From the staff standpoint, and that of others 
in the leadership, the year has been a most en- 
joyable one. There might be some feeling of 
frustration as to what didn’t quite get done, 
but that in no way detracts from the overall 
1982-83 record. 

Linder Doctor Adkins’ leadership the member- 
ship can feel comfortable that the same atmos- 
phere of concern, dedication and intensity will 
continue. The challenge to the membership will 
be to respond to that leadership. We are confi- 
dent it will. 


As the American Medical Association recently 
has noted, results of three separate polls related 
to regulation and the jurisdiction of the Federal 
Trade Commission over Medicine have contained 
some interesting messages for the profession. 

Among other things, the polls showed that the 
public image of the AMA improved by two per 
cent between 1981 and 1983, 
PUBLIC TRUST with 72 per cent of the public 
indicating a great deal or a fair 
amount of confidence in the AMA’s ability to 
propose fair and workable health policies. 

Significantly, all other groups covered by the 
surveys, including the federal government, con- 


gressional committees and labor unions, reflected 
declines in public confidence. 

Most important, however, the polls showed an 
increase in public preference for a local versus 
national approach to the regulation of Medicine. 
This preference had become a majority viewpoint 
as of March of this year. 

Along these same general lines, public opinion 
also apparently had crystallized in favor of a 
locally based approach to planning and develop- 
ment of health care policies. This Lrend was 
strongest among highly educated young people. 

In earlier polls, the public view was somewhat 
poorly defined when those surveyed were asked 
if they had more confidence in policies de- 
veloped by the government at the national level, 
or by officials and groups at the local level. 

This public expression of confidence in local 
health planning and regulation can’t be stressed 
too heavily in the face of the many forces and 
trends at work today. Physicians in particular 
are placed under even greater pressure to measure 
up to what the public expects. 

That’s why every effort and measure of sup- 
port must be put forth to make agencies like the 
West Virginia Board of Medicine viable, effec- 
tive and credible organizations. Physicians, 
in day-to-day dealings with individual patients 
and the public in general, must have a keen 
awareness of the trust and confidence placed in 
them. 

Professional and effective review programs 
toward assurance of the highest quality of care 
probably have never been more important. These 
programs can be done best by doctors, and 
should be so structured. 

We never have suggested that there is a 
particular or magic formula for such things as 
patient rapport and professional conduct and 
responsibility. Physicians know full well the 
importance of such components which must be 
a part of their practice. 

But the heat, if you will, is on all professionals 
in ever increasing degree. That’s obvious in 
legislative halls, in the sprawling administrative 
bureaucracy and anywhere else you might want 
to look. 

That’s why it is most encouraging to know 
that the public still feels self-regulation of 
physicians, rather than state or federal controls, 
is best. This is a public trust that must be 
accommodated. The alternatives are obvious, 
and NOT in the best interest of patients and the 
public. 


168 


The West Virginia Medical Journal 


GENERAL NEWS 


Congestive Heart Failure 
Convention Subject 


Dr. Warren T. Anderson, Morgantown cardi- 
ologist. will speak on ‘‘The Management of Con- 
gestive Heart Failure” during the 116th Annual 
Meeting of the State Medical Association. 

Doctor Anderson, Clinical Associate Profes- 
sor of Cardiology at West \irginia University 



School of Medicine, 
will talk during a 
“Symposium on Cardi- 
ovascular Diseases” 
which will constitute 
the second general 
scientific session on 
Saturday morning, 
August 27. 

The convention will 
be held August 25-27 
at the Greenbrier in 
White Sulphur Springs. 


Warren T. Anderson, M. D. The announcement 

of Doctor Anderson’s 
paper by the Program Committee completes 
arrangements for the combined business and 
scientific event. 


A recently-announced development, an innova- 
tion this year, will be a black-tie dinner on 
Saturday evening honoring outgoing and new 
officers of the State Medical Association and 
the Auxiliary. The “by-ticket only” dinner, the 
final event in the three-day schedule, also is ex- 
pected to be attended by the Presidents and 
spouses of the American Medical Association 
and neighboring states represented each year. 


475 Expected to Attend 

Some 475 physicians, spouses and others are 
expected to attend the convention, with the 
schedule to include: two sessions of the Associa- 
tion’s House of Delegates; two general scientific 
sessions; addresses by the AM A President, Dr. 
Frank J. Jirka, Jr., of Barrington, Illinois, and 
Dr. Samuel P. Asper of Philadelphia, President 
of the Educational Commission for Foreign 
Medical Graduates; a Saturday afternoon re- 



ception for Association members and guests; and 
the dinner Saturday evening, as noted. 

There will be some 20 scientific exhibits for 
viewing by conventioneers. 

About 18 affiliated societies, sections and com- 
mittees of the Association, and other medical 
groups also will have business and scientific ses- 
sions on Friday and Saturday, many in the form 
of breakfast and luncheon meetings. 

See the official program and related articles 
in this issue of The Journal for specific conven- 
tion activities and speakers. 

Doctor Adkins to be Installed 

Dr. Carl R. Adkins of Fayetteville, during the 
second House session on Saturday, will be in- 
stalled as Association President to succeed Dr. 
Harry Shannon of Parkersburg. 

Doctor Jirka will address the first House ses- 
sion Thursday afternoon, and Doctor Asper will 



Carl R. Adkins, M. D. 


oi 

fa 




r' 

ca 


August, 1983, Vol. 79, No. 8 


169 


deliver the keynote Thomas L. Harris Address 
during the opening exercises Friday morning. 

The first general scientific session, a 
“Symposium on Sexually Transmitted Diseases,” 
will follow the opening exercises Friday morning. 

The scientific session speakers, some of whom 
also will give talks at the affiliated society and 
section meetings, have been announced in pre- 
vious issues of The Journal. As noted, they are 
listed in the official program appearing in this 
issue. 

Doctor Shannon, a urologist, will deliver his 
Presidential address at the second House session 
on Saturday afternoon. Doctor Adkins, the in- 
coming President, is in emergency medicine at 
Raleigh General Hospital in Beckley. 

Doctor Anderson came to Morgantown in 
1977 from Washington, D.C., where he was 
Clinical Instructor in the Department of Medi- 
cine at Georgetown University (1971-77), and 
completed a cardiology fellowship at Walter 
Reed Army Medical Center (1971-73). 

Certification 

He is certified by the American Boards of 
Internal Medicine and Cardiovascular Disease, 
and is a Fellow of the American College of 
Cardiology, American College of Physicians, and 
Council of Clinical Cardiology. 

Doctor Anderson was graduated from Virginia 
Military Institute, and received his M. D. degree 
in 1967 from Temple University. He served his 
internship and residency at Letterman General 
Hospital in San Francisco. 


Convention Timetable 

The first general scientific session will fol- 
low 9 A. M. opening exercises on Friday, 
August 26. The Saturday session will begin 
at 9:30 A. M. 

The first session of the House of Delegates 
will be on Thursday afternoon, August 25, 
beginning at 2:30. The second session will 
be on Saturday afternoon beginning at 3:00. 


Luncheon For Past Presidents 

A luncheon honoring Past Presidents of the 
West Virginia State Medical Association will 
be held at the Greenbrier on Friday, August 
26, d uring the 116th Annual Meeting. 

Dr. John B. Markey of Charleston, immedi- 
ate Past President, will preside, and invita- 
tions have been extended to all the Associa- 
tion’s Past Presidents. 


The scientific exhibits, again to be housed in 
Eisenhower Hall, will be open from 1 to 5 P. M. 
on Thursday, and 8:30 A. M. to noon on Friday 
and Saturday. The exhibits are listed elsewhere 
in this issue of The Journal. 

The Association’s Council will hold a pre- 
convention meeting at 9:30 A. M. Thursday. 

Dinner Tickets on Sale 

Tickets for the Saturday evening dinner will 
be on sale at the Association and Auxiliary 
registration desks, beginning on Thursday 
morning, August 25. It will be necessary to pro- 
vide the Greenbrier with an attendance figure 
by late on Friday, August 26. 

The Annual Meeting of the Auxiliary to the 
State Medical Association, with Mrs. Richard S. 
Kerr of Morgantown the current President, as 
usual will hold its meeting in conjunction with 
that of the Association. The official Auxiliary 
program also appears in this issue of The 
Journal. 


Nominating Committee To Meet 
On Friday, August 26 

The State Medical Association’s Committee 
on Nominations will hold a 5 P. M. meeting 
on Friday, August 26, in the Washington 
Room of the Greenbrier. 

Under a 1980 By-Laws amendment, the 
Committee will submit to the House of 
Delegates at least two nominees for the fol- 
lowing offices: Vice President and Treasurer, 
and Delegate and Alternate to the American 
Medical Association. Only the name of one 
nominee will be necessary for the President 
Elect. 

Association By-Laws also provide that 
nominations may be made from the floor for 
these offices, to be filled by the House in 
balloting at its final session on Saturday, 
August 27, the final day of the Association’s 
116th Annual Meeting. 

Dr. Stephen I). Ward of Wheeling will serve 
as Chairman of the Committee on Nomina- 
tions, with other members to include: Drs. 

Antonio S. Licata of Weirton, Roland J. 
Weisser, Jr., of Morgantown, Nabal B. Giron 
of Romney, Cordell A. de la Pena of Clarks- 
burg, John A. Mathias of Buckhannon, Joseph 
T. Skaggs of Charleston and T. Keith Edwards 
of Bluefield. 


170 


The West Virginia Medical Journal 


Continuing Education 
Activities 


Here are the continuing medical education 
activities listed primarily by the West Virginia 
University School of Medicine for part of 
1983, as compiled by Dr. Robert L. Smith, 
Assistant Dean for Continuing Education, and 
J. Zeb Wright, Ph. D., Coordinator, Con- 
tinuing Education, Department of Community 
Medicine, Charleston Division. The schedule is 
presented as a convenience for physicians in plan- 
ning their continuing education program. (Other 
national, state and district medical meetings are 
listed in the Medical Meetings Department of 
The Journal. ) 

The program is tentative and subject to 
change. It should be noted that weekly confer- 
ences also are held on the Morgantown, Charles- 
ton and Wheeling campuses. Further information 
about these may be obtained from: Division of 
Continuing Education, WVU Medical Center, 
3110 MacCorkle Avenue, S. E., Charleston 
25304; Office of Continuing Medical Education, 
WVU Medical Center, Morgantown 26506; or 
Office of Continuing Medical Education, Wheel- 
ing Division, WVU School of Medicine, Ohio 
Valley Medical Center, 2000 Eoff Street, Wheel- 
ing 26003. 

Sept. 3, Morgantown, Treatment Options in 
Arthritis* 

Sept. 9-10, Morgantown, Ob/Gyn Teaching 
Days* 

Sept. 14, Charleston, Advances in Hypertension 

Sept. 16-17, Charleston. Advanced Trauma Life 
Support Course 

Oct. 1, Morgantown, Issues in Geriatric Medi- 
cine* 

Oct. 5, Charleston, Gastroenterology Update 
Oct. 14, Ophthalmology Conference 

Oct. 15, Morgantown, Common Problems in 
Nephrology* 

Oct. 28-29, Morgantown, Fourth Diagnostic 
Ultrasound Conference 
Oct. 29, Charleston, Oncology Seminar 

Nov. 3-5, Morgantown, Ninth Annual Hal 
Wanger Family Practice Conference* 

Nov. 11-12, Morgantown, Fourth Sports Medi- 
cine Symposium* 

°Held in conjunction with WVU home football game. 

August, 1983, Vol. 79, No. 8 


Regularly Soiled uletl Continuing 
Education Outreach Programs from 
WVU Medical Center/ 
Charleston Division 

Buckhannon, St. Joseph’s Hospital, first-floor 
cafeteria, 3rd Thursday, 7-9 P. M. — Aug. 
(summer break). 

Cabin Creek, Cabin Creek Medical Center, 
Dawes, 2nd Wednesday, 8-10 A. M. — Aug. 
10, “Common Eye Emergencies,” Robert 
O’Connor, M. D. 

Cassaway, Braxton Co. Memorial Hospital, 1st 
Wednesday, 7-9 P. M. — Aug. 3, “Diagnosis 
of Pulmonary Disorders,” Dominic Gaziano, 
M. D. 

Madison, 2nd floor. Lick Creek Social Services 
Bldg., 2nd Tuesday, 7-9 P. M. — Aug. 9, 
“Approach to the Peripheral Vascular Pa- 
tient,” Ali F. AbuRahma, M. D. 

Oak Hill, Oak Hill High School (Oyler Exit, N 
19) 4th Tuesday, 7-9 P. M. — Aug. (summer 
break ) . 

Welch, Stevens Clinic Hospital, 3rd Wednesday, 
12 Noon-2 P. M. — Aug. (summer break). 

IFhitesville, Raleigh-Boone Medical Center, 4th 
Wednesday, 11 A. M.-l P. M. - — Aug. (sum- 
mer break). 

Williamson, Appalachian Power Auditorium, 1st 
Thursday, 6:30-8:30 P. M. — Aug. (summer 
break ). 

Sept. 1, “Rational Use & Cost Containment in 
Antibiotic Therapy” (speaker to be an- 
nounced ). 


Convention Exhibits Site 
Eisenhower Hall 

Members, spouses and others are urged to 
view the scientific exhibits which will be on 
display during the State Medical Association’s 
116th Annual Meeting at the Greenbrier in 
White Sulphur Springs. 

The exhibits will be located in Eisenhower 
Hall, on the Shop Floor and adjacent to the 
theater. Exhibit hours will be from 1 to 5 
P. M. on Thursday, August 25, and from 8:30 
A. M. to noon on Friday and Saturday. 

Coffee breaks during the scientific sessions 
of the convention Friday and Saturday morn- 
ings in the theater will be provided for visiting 
the exhibits. 


171 



State Diabetes President 

Dr. Bruce S. Chertow of Huntington recently 
was elected President of the American Diabetes 
Association, West Virginia Affiliate. Doctor 
Chertow is Professor of Medicine and Chief, 
Section of Endocrinology at Marshall University 
School of Medicine. 



Medical journals once belonging to Dr. lessee 
Bennett, pioneer eighteenth century surgeon, are 
displayed by Dr. John M. Grubb, obstetrician-gy- 
necologist in Point Pleasant (Mason County). It is 
reported that Doctor Bennett performed the first 
cesarean section in America in Virginia in 1794. He 
later moved to Mason County where he died and is 
buried. The old journals were shown by Doctor 
Grubb during a recent meeting of the Mason County 
Medical Society in Point Pleasant. 


‘Specialty For All Ages’ AAFP 
Annual Meeting Theme 

The Miami Beach Convention Center will be 
the site of the 35th annual convention and 
scientific assembly of the American Academy of 
Family Physicians (AAFP) October 10-13. 

Delegates from the West Virginia Chapter, 
AAFP, will be Drs. F. Dale Simmons of Clarks- 
burg and Joseph A. Smith of Dunbar. 

This year’s theme, “Family Practice, a Spe- 
cialty for All Ages,” highlights the family 
physician’s capability of managing the entire 
family’s health care. 

Paul Harvey, radio, TV and newspaper com- 
mentator, will keynote the scientific program at 
1:30 P. M., Monday, October 10, at the Con- 
vention Center. 

Other lectures include “Fife Styles and 
Stress,” “Acquired Immune Deficiency Syndrome 
(AIDS),” and “Diet and Obesity.” 

This year’s program offers 12 educational 
activities and more than 100 practical topics 
specifically designed to acquaint family physi- 
cians with the latest medical advances. Some of 
the topics are breast mass, fractures in children, 
care and conditioning of the athlete, fetal 
monitoring, and aspects of aging. 

The Congress of Delegates, AAFP’s governing 
body, will convene prior to the Assembly to con- 
duct official business. The 112 delegates will 
meet October 8-10 at the Fontainebleau Hilton, 
Assembly headquarters. 

Nearly 700 family physicians will receive the 
degree of Fellow of the AAFP Tuesday, October 
11, at the Theater of the Performing Arts in 
Miami Beach. 



Officers and Directors of the West Virginia Gastrointestinal Society were named at its annual meeting 
held recently in Clarksburg. They are, from left, Drs. Sidney B. Jackson, Clarksburg, board member; Don- 
ald E. McDowell, Morgantown, Secretary-Treasurer; Catalino B. Mendoza, Clarksburg, retiring President; 
Duane D. VVebb, Huntington, President; Ronald D. Gaskins, Morgantown, President Elect; and William 
O. McMillan, Jr., and Eric P. Mantz, both of Charleston, board members. 


172 


The West Virginia Medical Journal 


State Medical Association Lists 
Names of New Members 

The following is a list by component societies of 
new members of the West Virginia State Medical 
Association elected from January 1 through June 
30, 1983: 

Boone 

Ernest Yutiamco Madison 


Brooke 

Richard Bombach Wheeling 


Cabell 

Ijaz Ahmad 
S. Ahmad Ettehadieh . 

John P. Gearhart 
Douglas Glover 
Colette Gushurst 
Roger G. Kimber, Jr. 

Jayshri Mody 

Alvaro Paz 
Tully Roisman 
Robert C. Touchon 
C. Danny Waldrop 
William E. Wheeler 

Central West Virginia 

Thomas La Mar Stahly... Summersville 

Eastern Panhandle 

Ronald J. Crisp..... Martinsburg 

Edward E. Volcjak. “ 


Huntington 

<( 


Hamlin 

Huntington 


O. P. Gosien 
Eleanor Navarro .. 
Dante R. Oreta 


Fayette 

Oak Hill 

Montgomery 

- Charleston 


Greenbrier Valley 


Malcolm S. Harris .. Union 

Thomas F. Mann Ronceverte 

Dorris A. Ragsdale “ 

Lynn N. Smith “ 

Lois Speiden “ 

Haven N. Wall Lewisburg 

Robert L. Wheeler Ronceverte 


Harrison 

Charles F. Chong Clarksburg 

John J. Crossen “ 

Amar N. Gulati “ 

James A. Knost “ 

Saad Mossallati.... “ 

Susan W. Miller. .. “ 

Michael C. Robinson “ 

James Weinstein “ 


Raymond O. Rushden Charleston 

Happy Verma 

Maheshwer B. Verma 

David Owen Wright — 


Logan 

Boppana Rao Prasada 


Whitman 


Marion 

Agnes M. Franz — Fairmont 

Sitha Rama Swamy Katragadda 

Harry G. Kennedy, Jr “ 

Tom Turner. “ 


Marshall 

Romeo Bihag Tan 


Moundsville 


Mason 

Suresh Kumar Agrawal Point Pleasant 

Mel P. Simon “ 

Richard L. Slack “ 


Mercer 

R. M. Bhagat ............. Bluefield 

Robert B. Miller . 

John G. Murray, Jr. Cool Ridge 

Charles M. Olmsted Bluefield 

Stephen P. Poolos .. .... . — 

Meryl A. Severson ~ Princeton 


Mingo 

Pastor C. Gomez Williamson 

C. H. Yajnik “ 

Sutin Srisumrid South Williamson, KY 

Subhash A. Vyas Williamson 


Monongalia 

Patricia Bayless 

Priscilla Gilman 
John P. Griffiths 
Janis Leigh Hurst 

Marian Swinker 

Paul Parker Williams 


Morgantown 

u 


Fairmont 

Morgantown 


Ohio 

Vincente P. Almario..... Wheeling 

Michael W. Blatt 

Rajai T. Khoury. “ 

Donald John Mirate “ 

William L. Noble 

Frederick J. Payne “ 

Ahmad Rahbar “ 

John Gregory Tellers “ 

Parkersburg Academy 

Juanito Aya-Ay Grantsville 

James Dauphin Parkersburg 

Van B. Elliott 

John Michael Foster 

Purisima Guerrero “ 

R. B. Henthorn “ 

Richard Johns “ 


Jefferson 

Michael R. P. Atherton. Ranson 

John A. Stefano “ 

Kanawha 

Antonio R. Cafoncelli.... Charleston 

Stephen Paul Cassis “ 

Glenn Crotty, Jr. “ 

Paul H. Derboven Tornado 

Kenneth M. Harman Charleston 

Henry Levenson “ 

Robert Thomas Linger, Jr. “ 

Stephen E. Perkins South Charleston 

Thomas Douglas Rapp..... ... Ripley 


Potomac Valley 

Henrv G. Tavlor 

Franklin 

Robert A. Gregg 

Preston 

Kingwood 

Masontown 

Patricia Haase 


J. E. Swanton 


Reedsville 

Mario C. Ramas 

Raleigh 

Beckley 

Cirilo Z. Villanueva 


Tygart’s Valley 

Robert M. Hollev 

Clarksburg 

Rex B. Kare 

Robert W. O'Donnell.. 


Grafton 

Elkins 


(Continued On Next Page) 


August, 1983, You. 79, No. 8 


173 


Student Members 

R. David Allara .. .. WVU, Morgantown 

John David Angotti .... WVU, Clarksburg 

David R. Ayers MU, Huntington 

Danny C. Blankenship WVU, Morgantown 

A. Thomas Bundy “ “ 

Brent Wilson Chapman .. . “ “ 

Lee C. Drinkard.... WVU, Wheeling 

Michael B. Edmond . WVU, Monongah 

Jackson L. Flanigan MU, Martinsburg 

Daniel Scott Frame .. - WVU, Morgantown 

Jo Ann Goldbaugh “ 

Kimberly Carol Irwin “ “ 

Jocelyn L. James WVU, Charleston 

Nancy Joseph MU, Huntington 

Maurice D. Kinsolving ... ._ WVU, Morgantown 

Susann Lea Lovejoy MU, Huntington 

Michele Maroon WVU, Morgantown 

Gary Lance Matheny WVU, Charleston 

Mark Robert McGinnis WVU, Morgantown 

Steven G. McLaughlin “ “ 

Kenneth F. McNiel MU, Huntington 

William R. Marchand WVU, Morgantown 

Debra Jean Panucci “ “ 

Lakshmikumar Pillai ... “ 

R. Michael Simpkins “ 

Teresa Lynn Skidmore “ 

Donna J. Slayton MU, Huntington 

Elizabeth Spangler.. “ “ 

Gary Allen Thompson WVU, Morgantown 

Richard K. Umstot, Jr. “ “ 

Richard M. Vaglienti “ “ 

Intern/Resident Members 

Hasan Behdadnia Wheeling 

Michael W. Burkhart Martinsburg 

Richard A. Capito Charleston 

Max A. Harned Wheeling 

Douglas C. McCorkle Morgantown 

Frank L. Schwartz “ 

Alfred Seco-Garcia Wheeling 


1983 Roster Corrections 

The following physicians have notified 
headquarters staff of corrections in specialty 
listings as they appear in the 1983 Roster of 


Members of the West Virginia State Medical 


Association: 

• ■ o 

Specialty 

Society 

Name 

Change 

Cabell 

Frank Rivas 

CD 

Hancock 

Timothy A. Brown 

D 

Harrison 

Harry Bishop 

R 


Teodoro Medina 

I-GF 


Robert I. Mosenfeldei 

• ObG 

Jefferson 

R. F. Rickel, Jr. 

GP 

Kanawha 

Jerry Maliska 

EM-GP 


Joseph T. Skaggs 

Adm 

Monongalia 

Charlene F. Horan 

I 

Parkersburg 

Frederick C. Whittier 

I-NEP 

Academy 

Anantrai Vora 

Pd 

Tygart’s 

Valley 

J udith A. Wolfe 

OTO-A 


Review A Book 


The following books have been received by the 
Headquarters Office of the State Medical Associa- 
tion. Medical readers interested in reviewing any 
of these volumes should address their requests to 
Editor, The West Virginia Medical Journal, Post 
Office Box 1031, Charleston 25324. We shall be 
happy to send the books to you, and you may 
keep them for your personal libraries after sub- 
mitting to The Journal a review for publication. 

General Ophthalmology, 10th Edition, by 
Daniel Vaughan, M. D.; and Taylor Asbury, 
M. D. 407 pages. Price $17. Lange Medical 
Publications, Los Altos, California 94022. 
1983. 

Review of Medical Physiology, 11th Edition, 
by William F. Ganong, M. D. 643 pages. Price 
$20. Lange Medical Publications, Los Altos, 
California 94022. 1983. 

Handbook of Pediatrics, 14th Edition, by 
Henry K. Silver, M. D.; C. Henry Kempe, M. D.; 
and Henry B. Bruyn. M. D. 883 pages. Price 
$13. Lange Medical Publications, Los Altos, 
California 94022. 1983. 

Handbook of Poisoning, 11th Edition, by 
Robert H. Dreisbach, M. D. 632 pages. Price 
$11. Lange Medical Publications, Los Altos, 
California 94022. 1983. 


The 1983 Program Committee 

Chairman of the Program Committee for 
the 116th Annual Meeting of the West Vir- 
ginia State Medical Association is Dr. David 
Z. Morgan of Morgantown. Other Committee 
members are Drs. Jean P. Cavender of 
Charleston, Michael J. Lewis of St. Marys, 
Kenneth Scher of Huntington, Roland J. 
Weisser of Morgantown, and Carl R. Adkins 
of Fayetteville. 


No Registration Fee for Members 

Members of the West Virginia State Medical 
Association will not be assessed a registration 
fee for the 116th Annual Meeting at the 
Greenbrier in White Sulphur Springs, August 
25-27. 

Interns, residents and medical students also 
will be registered without charge. 

There will be a registration fee of $75 for 
out-of-state physicians attending the meeting. 


174 


The West Virginia Medical Journal 



Auxiliary Completes Program 
For 59th Annual Meeting 

Mrs. John G. Bates of Cuthbert, Georgia, will 
be among honored guests when the Auxiliary to 
the West Virginia State Medical Association 
holds its 59th Annual Meeting at the Greenbrier 
in White Sulphur Springs August 25-27. 

The meeting again will be held concurrently 
with the Annual Meeting of the State Medical 
Association. Mrs. Bates was installed in June as 
the new President of the American Medical Asso- 
ciation Auxiliary. She will deliver the keynote 
address during the opening Auxiliary session 
beginning at 9:30 A. M. on Friday, August 26. 

Also addressing the Auxiliary will be Mrs. 
William D. Hughes of Montgomery. Alabama, 
President of the Southern Medical Association 
Auxiliary. 

More than 200 spouses of physicians are ex- 
pected to attend the Auxiliary’s business sessions, 
over which Mrs. Richard S. Kerr of Morgantown, 
the Auxiliary’s President, will preside. 

An invitation has been extended to all Aux- 
iliary members to attend the first session of the 
State Medical Association's House of Delegates 
on Thursday, August 25, at 2:30 P. M. in Chesa- 
peake Hall. Dr. Frank J. Jirka. Jr., AMA Presi- 
dent, will be the principal speaker. Auxiliary 



Mrs. Richard S. Kerr 



Mrs. John G. Bates Mrs. William D. Hughes 


members also are invited to attend formal open- 
ing ceremonies of the Association’s 116th Annual 
Meeting at 9 A.M. on Friday, August 26, in the 
theater. Dr. Samuel P. Asper, President, Educa- 
tional Commission for Foreign Medical Gradu- 
ates, Philadelphia, will deliver the keynote 
Thomas L. Harris Address. 

Dr. Harry Shannon of Parkersburg, President 
of the State Medical Association, will be recog- 
nized for brief remarks prior to Mrs. Bates’ 
address Friday morning. 

Mrs. Hughes will make her address during the 
second general session Saturday morning. During 
this session also, Mrs. Bates will install Mrs. 
T. Keith Edwards of Bluefield as President, and 
other new officers, and Mrs. Edwards will deliver 
her inaugural address. 

For other scheduled business and sports ac- 
tivities, see the official Auxiliary program in 
this issue of The Journal. 


Doctor Fix Heads Organization 
Of State Presidents 

L. Walter Fix, M. D., of Martinsburg, Presi- 
dent of the West Virginia State Medical Associa- 
tion in 1980-81, assumed the Presidency of the 
Organization of State Medical Association Presi- 
dents at an annual business meeting in Chicago 
in June. 

OSMAP has a membership of current and past 
presidents, and presidents-elect. of state medical 
associations and societies. It is active in a num- 
ber of endeavors, including presentation of 
forums on medical affairs and other programs 
held in conjunction with annual and interim 
meetings of the American Medical Association’s 
House of Delegates. 

Doctor Fix first served as a member of 
OSMAP's Steering Committee, and for the past 
year has been President-Elect. 


August, 1983, Vol. 79. No. 8 


175 




Convention Exhibit To Feature 
Local Health Departments 

Exhibits at, the West Virginia State Medical 
Association’s August 25-27 Annual Meeting at 
the Greenbrier will include one representing 
stepped-up efforts to provide more information 
for the medical community about local health 
department activities. 

L. Clark Hansbarger, M. D., West Virginia’s 
Director of Health, said he will provide a display 
of local health department activities and services, 
along with material identifying local health 
officers who serve throughout the state. 

“I’m going to man that exhibit myself,” 
Doctor Hansbarger said. 

For the second year, the Annual Meeting pro- 
gram will include a 1 P. M. session on Thursday, 
August 25, in the Greenbrier’s Jackson Room 
of state and local health officials to provide still 
more ongoing dialogue and discussion. Other 
physicians are invited to attend and participate 
in this meeting. 


Sports Events Again Planned 
For Annual Meeting 

Time will be at a premium, but physicians 
and auxiliary members plan to work annual golf 
and tennis competition into the tight business 
and scientific program schedule for the State 
Medical Association’s Annual Meeting at the 
Greenbrier August 25-27. 

Dr. William C Morgan of Charleston is the 
defending champion in the Medical Golf Tourna- 
ment. The women’s golf tournament was rained 
out in 1982. 

Winners of last year’s men’s doubles tennis 
competition were Drs. Maurice A. Mufson of 
Huntington and Jose Oyco of Beckley. Results 
of the women’s tennis competition were not 
available. 


MU Graduate’s Paper Wins 

Dr. Douglas W. Given, a 1983 graduate of the 
Marshall University School of Medicine, pre- 
sented the winning student research paper at the 
Southern Health Association annual meeting in 
June. 

Doctor Given, a Strange Creek native, focused 
on farming accidents. 

Students from Marshall, West Virginia Uni- 
versity and the University of North Carolina 
presented papers at the Charleston meeting. 


Medical Meetings 


Aug. 1-3 — International Society for Sexually Trans- 
mitted Disease Research, Seattle. 

Aug. 1-5 — Am. Venereal Disease, Seattle. 

Aug. 22-24 — Spinal Cord Regeneration & Recent De- 
velopments (Am. Paraplegia Society), Las 
Vegas. 

Aug. 25-27 — 116th Annual Meeting, W. Va. State 
Medical Assn., White Sulphur Springs. 

Aug. 26 — W. Va. Chapter, Am. College of Emergency 
Physicians, White Sulphur Springs. 

Sept. 7-10 — Peripheral Vascular Disease Symposium 
(Saint Anthony Hospital), Columbus, OH. 

Sept. 29-Oct. 1 — Am. Assoc, for the Surgery of 
Trauma. 

Sept. 29-Oct. 2 — Am. Society of Internal Medicine, 
San Francisco. 

Sept. 30-Oct. 1 — W. Va. Chapter, Am. College of 
Surgeons, Morgantown. 

Oct. 2-5 — Am. Neurological Assoc., New Orleans. 

Oct. 5-8 — Am. Thyroid Assoc., New Orleans. 

Oct. 7-8 — AMA Congress on Occupational Health, 
Beachwood, OH. 

Oct. 16-21 — Am. College of Surgeons, Atlanta. 

Oct. 22-27 — Am. Academy of Pediatrics, San Fran- 
cisco. 

Oct. 23-26 — Am. College of Gastroenterology, Los 
Angeles. 

Oct. 23-27 — Am. College of Chest Physicians, 
Chicago. 

Oct. 24-27 — Am. College of Emergency Physicians, 
Atlanta. 

Oct. 26-30 — Am. Academy of Child Psychiatry, San 
Francisco. 

Nov. 6-9 — Scientific Assembly, Southern Medical 
Assoc., Baltimore. 

Nov. 7-9 — Am. Medical Women’s Assoc., Dearborn, 
MI. 

Nov. 18-22 — Gerontological Society of Am., San 
Francisco. 

Nov. 30-Dec. 1 — Am. College of Chemosurgery, 
Chicago. 

1984 

Jan. 19-21 — Neurosurgical Society of the Virginias, 
Williamsburg, VA. 

Jan. 27-29 — 17th Mid- Winter Clinical Conference, 
Charleston. 

Feb. 12-15 — W. Va. Perinatal Assoc., Snowshoe. 

March 17 — Annual Meeting, W. Va. Affiliate, 
American Diabetes Assoc., Wheeling. 


176 


The West Virginia Medical Journal 



CONVENTION PROGRAM 


116th ANNUAL MEETING 

of the 

West Virginia State Medical Association 
THE GREENBRIER, WHITE SULPHUR SPRINGS 
August 25-27, 1983 


THURSDAY MORNING 
August 25 

(Eastern Daylight Time) 

9:00-5:00 — Registration, Registration Lobby. 

9:30 — Pre-Convention Meeting of the Council. John 
B. Markey, M.D., Presiding (Fillmore 
Room, with Luncheon in Tyler Room). 

THURSDAY AFTERNOON 

1:00 — Public Health-Local Health Officer Con- 
ference (Jackson Room). 

2:30 — First Session of the House of Delegates. 

Harry Shannon, M.D., Presiding (Chesa- 
peake Hall). 

Invocation — Joe N. Jarrett, M.D. 

Address: Frank J. Jirka, Jr., M.D., Presi- 
dent, American Medical Association. 

Recognition of AMA-ERF Grants to the 
West Virginia University and Marshall 
University Schools of Medicine. 

Business Meeting. 

5:00 — Committee on Resolutions. John J. Mahood, 
M.D., Presiding (Directors’ Room). 

FRIDAY MORNING 
August 26 

8:30-5:00 — Registration, Registration Lobby. 

Breakfast Meetings 

7:30 — Section on Internal Medicine. Maurice A. 

Mufson, M.D., Presiding (Tyler Room). 

Guest Speaker: George J. Pazin, M.D. 

Subject: “Genital Herpes — Signs, Sex- 

ual Relationships and Source Contacts 
of Women with First-Time Disease.” 

7:30 — Section on Dermatology. William A. Welton, 
M.D., Presiding (Directors’ Room). 

Case Presentations. 


7:30 — Section on Surgery. Robert J. Reed III, M.D., 
Presiding (Pierce Room). 

Guest Speaker: Alvin L. Watne, M.D., 

Professor and Chairman of Surgery, 
West Virginia University School of 
Medicine, Morgantown. Subject: 
“Emergent Surgery for Acute Colicys- 
titis.” 

Opening Exercises 
(Theater) 

9:00 — Call to Order — Harry Shannon, M.D., Presi- 
dent, West Virginia State Medical Asso- 
ciation. 

Invocation — Joseph T. Skaggs, M.D. 

Address of Welcome — Harry Shannon, 
M.D. 

Introduction of David Z. Morgan, M.D., 
1983 Program Committee Chairman, and 
other Members of his Committee. 

“The Thomas L. Harris Address.” 

Samuel P. Asper, M.D., President, Educa- 
tional Commission for Foreign Medical 
Graduates, Philadelphia, and Professor 
of Medicine, The Johns Hopkins Univer- 
sity, Baltimore. Subject: “Strengths and 
Weaknesses of the U. S. Role in Inter- 
national Medicine.” 

First General Session 
9:45-12:30 

“Symposium on Sexually Transmitted 
Diseases” 

David Z. Morgan, M.D., Moderator 
9:45 — Edmund C. Tramont, M.D., COL, MC, USA, 
Chief, Infectious Diseases, Department of 
Bacterial Diseases, Walter Reed Army 
Institute of Research, Washington, DC. 
Subject: “Syphilitic and Gonococcal In- 
fections.” 


August, 1983, Vol. 79, No. 8 


177 


10:15 — Lee P. Van Voids, M.D., Infectious Diseases 
and Coordinator of Medical Education, 
Department of Medicine, Hamot Medical 
Center, Erie, Pennsylvania (formerly 
Associate Professor of Medicine, Mar- 
shall University School of Medicine, 
Huntington). Subject: “Non - Luetic, 

Non-Gonococcal Venereal Diseases.” 

10:45 — Coffee Break to Visit Exhibits. 

11:00 — George J. Pazin, M.D., Associate Professor of 
Medicine, University of Pittsburgh 
School of Medicine, Pittsburgh. Subject: 
“Transmissible Diseases of the Gay Pa- 
tient.” 

11:30 — Jack L. Summers, M.D., Chairman, Depart- 
ment of Urology, Akron City Hospital, 
Akron, Ohio, and Professor of Urology, 
Northeastern Ohio Universities College 
of Medicine, Akron. 

Subject: “Sexual Mores in the 1980s.” 

12:00 — Questions, Answers and Discussion. 

12:30 — Recess for Lunch. 

FRIDAY AFTERNOON 

12:30 — Luncheon Honoring Past Presidents of the 
West Virginia State Medical Association. 
John B. Markey, M.D., Presiding (Tyler 
Room) . 

12:30 — Cancer Committee. Business Meeting. Alvin 

L. Watne, M.D., Presiding (Jackson 
Room) . 

12:30 — West Virginia Medical Institute, Inc., Board 
of Trustees Meeting. Harry S. Weeks, 
Jr., M.D., Presiding (Virginia Room). 

1:00 — West Virginia Chapter, American College of 
Emergency Physicians. Roger Frome, 

M. D., Presiding (Pierce Room). 

Guest Speakers: Warren T. Anderson, 

M.D. Subject: “Update on Emergency 

Cardiology.” 

William E. Walker, M.D., Huntington. 
Subject: “Update on Toxicology.” 

1:00 — West Virginia State Neurosurgical Society. 

Carrel M. Caudill, M.D., Presiding 
(Buchanan Room). 

Business meeting. 

2:00 — West Virginia Chapter, American Academy 
of Pediatrics. Kenneth L. Wible, M.D., 
Presiding (Fillmore Room) . 

Guest Speakers: Karen A. Connors, Ph.D., 
Adjunct Assistant Professor of Pediatrics 
and Infant Stimulation Specialist, West 
Virginia University Affiliated Center for 
Developmental Disabilities, Morgantown; 
and Jan K. Nash, M.S.W., Developmental 
Disabilities Coordinator, Valley Com- 
munity Mental Health Center, Morgan- 
town. Subject: “Enhancing the Coping 
Strategies and Parenting Skills of Fam- 
ilies with Developmental^ Delayed In- 
fants.” 


2:00 — Section on Orthopedic Surgery. Darrell C. 

Belcher, M.D., Presiding (West Virginia 
Room) . 

Guest Speaker: Robert H. Cofield, M.D., 
Associate Professor, Mayo Medical 
School; Consultant, Orthopedic Surgery, 
Mayo Clinic, Rochester, Minnesota. Sub- 
ject: “Management of Rotator Cuff Dis- 
ease.” 

2:00 — West Virginia District Branch, American 
Psychiatric Association. Ralph S. Smith, 
Jr., M.D., Presiding (Lee Room). 

Guest Speakers: Armando R. Favazzo, 

M.D,. Professor of Psychiatry, Univer- 
sity of Missouri Medical Center, Colum- 
bia. Subject: “Cultural Context of Self- 
Mutilation.” 

5:00 — Committee on Nominations. Stephen D. 

Ward, M.D., Presiding (Washington 
Room) . 

FRIDAY EVENING 

6:00 — Cocktail Party. The University of Virginia 
Medical School Foundation. William C 
Morgan, M.D., host (Old White Club). 

6:00 — Cocktail Party. West Virginia Chapter, 
Medical College of Virginia Alumni 
Association. A. Thomas McCoy, M.D., 
in charge (Old White Club). 

6:30 — Les Batards Reception. L. Walter Fix, M.D., 
in charge (Virginia Room). 

6:30 — Cocktail Party. West Virginia University 
Alumni Association. Richard A. DeVaul, 
M.D., in charge (Spring Room). 

SATURDAY MORNING 
August 27 

9:00-2:00 — Registration, Registration Lobby. 

Breakfast Meetings 

8:00 — Section on Urology. John A. Belis, M.D., 
Presiding (Jackson Room). 

Guest Speaker: Jack L. Summers, M.D. 

Subject: “Iridium 192 Therapy for 

Carcinoma of the Prostate.” 

8:00 — West Virginia Gastrointestinal Society. 

Duane D. Webb, M.D., Presiding (Direc- 
tors’ Room). 

Guest Speaker: Doctor Webb. Subject: 

“Hepatitis Vaccine and Antigens.” 

8:00 — West Virginia Radiological Society. Johnsey 
L. Leef, Jr., M.D. Presiding (Lee Room). 

Guest Speaker: Peter Armstrong, M.D., 

Professor and Vice Chairman, Depart- 
ment of Radiology, University of Vir- 
ginia, Charlottesville. Subject: “Radi- 
ology of Diffuse Lung Disease.” 


178 


The West Virginia Medical Journal 


Second General Session 
(Theater) 

9 : 30 - 12:15 

“Symposium on Cardiovascular Diseases” 

Moderator: Jean P. Cavender, M.D. 

9:30 — John C. Alexander, Jr., M.D., Chief, Section 
of Cardiothoracic Surgery, West Virginia 
University School of Medicine, Morgan- 
town. Subject: “Cardiovascular Sur- 

gery — An Update.” 

10:15 — Stafford G. Warren, M.D., Clinical Professor 
of Medicine, WVU Charleston Division. 
Subject: “New Developments in the 

Management of Cardiac Arrhythmias.” 

11:00 — Coffee Break to Visit Exhibits. 

11: 15 — Warren T. Anderson, M.D., Clinical Associate 
Professor of Cardiology, West Virginia 
University School of Medicine, Morgan- 
town. Subject: “The Management of 

Congestive Heart Failure.” 

12:00 — Questions, Answers and Discussion. 

12:15 — Recess for Lunch. 

SATURDAY AFTERNOON 

12:00 — Publication Committee. Stephen D. Ward, 
M.D., Presiding (Jackson Room). 

12:00 — West Virginia State Society of Anesthesio- 
logists. Jeanne A. Rodman, M.D., Pre- 
siding (Directors’ Room) . 


Guest Speaker: John C. Alexander, Jr., 

M.D. Subject: “Problems in Anes- 

thesia Unique to Cardiovascular Sur- 
gery.” 

3:00 — Second and Final Session of the House of 
Delegates. Harry Shannon, M.D., Pre- 
siding (Chesapeake Hall). 

Invocation — Robert D. Hess, M.D. 

Presidential Address: Harry Shannon, 

M.D. 

Presentation of New Officers of Auxiliary 
to the West Virginia State Medical 
Association. 

Presentation of Honor Guests. 

Business Meeting. 

Election of Officers. 

Installation of Carl R. Adkins, M.D., Fay- 
etteville, as President of the West Vir- 
ginia State Medical Association. 

SATURDAY EVENING 

7:00 — Reception for West Virginia State Medical 
Association Members and Guests (Chesa- 
peake Terrace). 

8:00 — Dinner Honoring Officers of the West Vir- 
ginia State Medical Association and 
Auxiliary (Chesapeake Hall). 


August, 1983, Vol. 79, No. 8 


179 


A WORD OF THANKS 


The 1983 Program Committee, and the officers and members of the West Virginia 
State Medical Association, wish to acknowledge with sincere thanks grants received 
from the following firms to help support the Scientific Program for this year’s 
1 16th Annual Meeting. 


CIBA PHARMACEUTICAL COMPANY 
Northeastern Region 
King of Prussia, PA 

GEIGY PHARMACEUTICALS 
Kingston, PA 

HOECHST-ROUSSEL PHARMACEUTICALS, INC. 
Somerville, NJ 

HOSPITAL & PHYSICIANS SUPPLY COMPANY 
Charleston, WV 

ELI LILLY AND COMPANY 
and DISTA PRODUCTS COMPANY 
Indianapolis, IN 


PARKE-DAVIS 
DIVISION OF 

WARNER-LAMBERT COMPANY 
Morris Plains, NJ 

A. H. ROBINS COMPANY 
Richmond, VA 

WILLIAM H. RORER, INC. 

Fort Washington, PA 

ROXANE LABORATORIES, INC. 
Columbus, OH 

SMITH KLINE & FRENCH LABORATORIES 
Philadelphia, PA 


THE UPJOHN COMPANY 
Kalamazoo, MI 


(The firms listed above are those which had allocated funds to the Scientific Program as this issue 
of the The Journal went to press. Additional contributors will be listed in the Official Program to be 
distributed at the Greenbrier.) 


180 


The West Virginia Medical Journal 


DELEGATES AND ALTERNATES 


BOONE (2) — Delegates, Robert B. Atkins and 
Manuel T. Uy, Madison. Alternates, Sriramloo 
Kesari and Probhond Chinuntdet, Madison. 

BROOKE (2) — Delegates, Rogelio L. Velarde, 
Follansbee; and Richard Bombach, Wheeling. Alter- 
nates, Leticia Peralta-Velarde, Follansbee; and W. 
T. Booher, Jr., Wellsburg. 

CABELL (14) — Delegates, Stephen K. Wolfe, Jack 
Leckie, Charles E. Turner, Robert R. Dennison, Jr., 
William L. Neal, Tara Sharma, John D. Harrah, Earl 

J. Foster, John Gearhart, M. Bruce Martin, Joseph 

B. Touma, Robert W. Lowe, Winfield C. John and 

S. Bruce Chandor, Huntington. Alternates, Hossein 
Sakhai, Jose I. Ricard, Robert L. Bradley, Thomas F. 
Scott, Roy A. Edwards, Jr., N. G. Baranetsky and 
Gary G. Gilbert, Huntington; W. W. Mills and 
H. S. Mullens, Kenova; K. V. Raman, John A. Hunt, 
W. F. Daniels, Jr., Kenneth Scher and Seyed H. 
Hadi-Sadegh, Huntington. 

CENTRAL WEST VIRGINIA (3) — Delegates, 
Joseph B. Reed, Buckhannon; Alfred J. Magee, Sum- 
mersville; and Greenbrier Almond, Buckhannon. 
Alternates, John A. Mathias, Buckhannon; and 
Frank A. Scattaregia, Weston. 

EASTERN PANHANDLE (4)— Delegates, Fran- 
cisco D. Sabado, Jr., John S. Palkot, L. Walter Fix 
and George C. Soteropoulos, Martinsburg. Alter- 
nates, C. Vincent Townsend, Robert S. Strauch, R. J. 
Estogoy and Edward P. Quarantillo, Jr., Martins- 
burg. 

FAYETTE (3) — Delegates, Joe N. Jarrett and 
Serafino S. Maducdoc, Jr., Oak Hill; and Rolando 

C. Ramirez, Montgomery. Alternates, Honorato M. 
Aguila and Chuan H. Lee, Oak Hill; and Adin L. 
Timbayan, Montgomery. 

GREENBRIER VALLEY (4)— Delegates, Stephen 
L. Sebert, Fairlea; Romeo R. Ednacot, Ronceverte; 
Harvey A. Martin, White Sulphur Springs; and 
Charles E. Weinstein, Ronceverte. Alternates, Robert 

K. Modlin, Benjamin L. Plybon, Lynn N. Smith and 
Robert L. Wheeler, Ronceverte. 

HANCOCK (4) — Delegates, Pedro R. Montero, Jr., 
Chester; Timothy A. Brown, Antonio S. Licata and 
Thomas J. Beynon, Weirton. 

HARRISON (7) — Delegates, James E. Bland, 
James Genin, Joseph D. Wright, John A. Bellotte, 
Erlinda L. de la Pena, Clarksburg; Sidney B. Jack- 
son, Bridgeport; and Robert D. Hess, Clarksburg. 
Alternates, Louis C. Palmer, Bridgeport; Chinmay 
K. Datta, Cordell A. de la Pena, George W. Shehl, 

T. H. Chang and David A. Lynch, Clarksburg. 

JEFFERSON (2) — Delegate, L. Mildred Williams, 
Charles Town. Alternate, S. K. G. Menon, Ranson. 


KANAWHA (21)— Delegates, Alberto G. Capin- 
pin, Charleston; W. Alva Deardorff, South Charles- 
ton; Donald E. Farmer, Robert L. Ghiz, Carl B. 
Hall, Echols A. Hansbarger, Jr., Sherman E. Hat- 
field, Charleston; George W. Hogshead, Nitro; James 
W. Lane, K. G. MacDonald, Sr., Tony Majestro, 
Jimmy L. Mangus, John B. Markey, Lionel Nair, 
Robert B. Point, Warren Point, Charleston; Richard 
C. Rashid, South Charleston; William C. Revercomb, 
Jr., Charleston; Carl J. Roncaglione, South Charles- 
ton; and George A. Shawkey and Joseph T. Skaggs, 
Charleston. Alternates, Adla Adi, Clinton A. Briley, 
Jr., William H. Carter, Robert James Clubb, George 
V. Hamrick, Fred F. Holt, Thomas J. Janicki, Alberto 
C. Lee, Rogelio T. Lim, Eric P. Mantz, William O. 
McMillan, Jr., William C Morgan, Jr., Pejawar M. 
Rao, William G. Sale, Richard H. Sibley, Charles- 
ton; Joseph A. Smith, Dunbar; and George E. Tomas, 
Alfredo C. Velasquez, Charles C. Weise, Ronald L. 
Wilkinson and John F. Zeedick, Charleston. 

LOGAN (4) — Delegates, Chanchai Tivitmahaisoon, 
Logan; Thomas P. Long, Man; Herbert D. Stern, 
Logan; and Enrico V. Rallos, Gilbert. Alternates, 
Subhash Bhanot, West Logan; Carlos F. DeLara, 
Logan; Noor Laynab, Whitman; and Alberto M. 
Garma, Logan. 

MARION (4) — Delegates, Babu R. Devabhakthuni, 
Jack S. Koay, Guy David Leveaux, Mack I. Mc- 
Clain and Stanard L. Swihart, Fairmont. Alternates, 
Michael A. Grant, Chi Meen Lee, David M. McLellan, 
William L. Mossburg and P. Kent Thrush, Fairmont. 

MARSHALL (3) — Delegates, Carlos C. Jimenez, 
Kenneth J. Allen and Carl L. Anderson, Glen Dale. 
Alternate, Jose J. Ventosa, Jr., Glen Dale. 

MASON (2) — Delegates, Richard L. Slack and 
Aarom Boonsue, Point Pleasant. Alternate, Mel P. 
Simon, Point Pleasant. 

McDOWELL (3) — Delegates, John S. Cook, Rich- 
ard O. Gale and Louis A. Vega, Welch. Alternates, 
Bernard M. Swope, Vernon J. Magnus and Arthur 
Allen Carr, Welch. 

MERCER (7) — Delegates, David F. Bell, Jr., and 
J. E. Blaydes, Jr., Bluefield; Mario Cardenas and 
Frank J. Holroyd, Princeton; John J. Mahood, Blue- 
field; William Prudich, Montcalm; and Edward M. 
Spencer, Bluefield. 

MINGO (3) — Delegates, Edward B. Headley, Del- 
barton; Nikhanth Purohit and Diane E. Shafer, Wil- 
liamson. Alternate, C. H. Yajnik, Williamson. 

MONONGALIA (15) — Delegates, Donald C. Car- 
ter, Ralph W. Ryan, George A. Curry, Eric T. Jones, 
J. David Blaha, A. Hugh Lindsay, David Z. Morgan, 
Robert L. Smith, Herbert E. Warden, Roland J. 
Weisser, Jr., Orlando F. Gabriele, William A. Neal, 


August, 1983, Vol. 79, No. 8 


181 


Martha D. Mullett, Richard S. Kerr and J. W. Kessel, 
Morgantown. Alternates, James G. Arbogast, Robert 
Bettinger, K. Douglas Bowers, Jr., Thomas S. Clark, 
Thomas W. Crosby, Anthony G. Di Bartolomeo, John 
L. Fullmer, R. Brooks Gainer II, Frank C. Griswold, 
Paul J. Jakubec, Michael T. Hogan, Roger E. King, 
Lawrance S. Miller and Alvin L. Watne, Morgan- 
town. 

OHIO (10) — Delegates, George E. Bontos, Robert 
S. Robbins, James C. Durig, D. L. Latos, Milton E. 
Nugent, Robert J. Reed III, M. D. Reiter, Stephen 
D. Ward, Harry S. Weeks, Jr., and D. Verne Mc- 
Connell, Wheeling. 

PARKERSBURG ACADEMY (8) — Delegates, 
Michael J. Lewis, St. Marys; Billie M. Atkinson, 
Parkersburg; Logan W. Hovis, Vienna; and Paul 
W. Burke, William E. Gilmore, John E. Beane and 
Robert F. Gustke, Parkersburg. 

POTOMAC VALLEY (3)— Delegates, Jeffrey S. 
Life, Romney; and Paul T. Healy and James C. 
Bosley, Keyser. Alternates, Suratkal V. Shenoy and 
Robert W. McCoy, Jr., Keyser. 

PRESTON (2) — Delegates, Patricia Haase, Mason- 
town; and Thomas A. Haymond, Reedsville. Alter- 
nates, John W. Trenton, Kingwood; and William H. 
Harriman, Jr., Terra Alta. 


RALEIGH (8) — Delegates, Norman W. Taylor, 
Jose L. Oyco, Michael T. Webb, Nancy R. Webb, 
Worthy W. McKinney, William D. McLean, William 
C. Covey, Jr., and A. Allen Bliss, Beckley. Alter- 
nates, S. L. Francis, Lamberto C. Maramba, Isidro 
G. Zarsadias, Jr., Iligino Salon, Mario C. Ramas, 
Prospero B. Gogo, Richard D. Richmond, and T. 
Rosal Rojas, Jr., Beckley. 

SUMMERS (2) — Delegate, Eduardo L. Jimenez, 
Hinton. Alternate, Chandra P. Sharma, Hinton. 

TYGART’S VALLEY (6) — Delegates, Karl J. 
Myers, Jr., Philippi; Gene W. Harlow, Grafton; 
Michael M. Stump V, Elkins; Halberto G. Cruz, 
Philippi; and Jerome C. Arnett, Jr., and Hugh H. 
Cook, Jr., Elkins. Alternates, Robert R. Rector and 
James B. Magee, Elkins; Samuel M. Santibanez, 
Grafton; Mary E. Myers, Philippi; and Melanio D. 
Acosta, Jr., Parsons. 

WESTERN (3) — Delegates, Herminio L. Gam- 
ponia, Spencer; James T. Hughes and Ali H. Morad, 
Ripley. 

WETZEL (2) — Delegates, Donald A. Blum and 
K. M. Chengappa, New Martinsville. 

WYOMING (2) — Delegates, Frank J. Zsoldos and 
Ross E. Newman, Mullens. 


Reception Committee 


Frank J. Holroyd 
Harry S. Weeks, Jr. 
Harry Shannon 
David Z. Morgan 
Carl R. Adkins 
George A. Shawkey 
Stephen D. Ward 
Robert R. Weiler 

Joseph A. Smith 
Carl J. Roncaglione 
Jack Leckie 
Thomas F. Scott 
Robert D. Hess 
Roger E. King 
Worthy W. McKinney 
Sherman E. Hatfield 


John B. Markey 
Arthur A. Abplanalp 
John J. Mahood 
William E. Gilmore 
L. Walter Fix 
John A. Mathias 
Norman W. Taylor 
Joseph J. Renn III 

Charles C. Weise 
Joseph T. Skaggs 
D. L. Latos 
George W. Hogshead 
Jean P. Cavender 
George A. Curry 
John A. Bellotte 
Richard S. Kerr 


David B. Gray 
Robert R. Rector 
Diane E. Shafer 
Catalino B. Mendoza, Jr. 
Herbert D. Stern 
L. Mildred Williams 
Warren Point 
Charles E. Turner 
Cordell A. de la Pena 


182 


The West Virginia Medical Journal 


Official Program 
AUXILIARY 

to the 

West Virginia State Medical Association 

59th Annual Meeting 

THE GREENBRIER 
White Sulphur Springs 

August 25-27, 1983 


THURSDAY AFTERNOON 
August 25 

2:00-5:00 — Registration, Lower Lobby. 

2:30 — First Session of the House of Delegates, West 
Virginia State Medical Association 
(Chesapeake Hall). 

Address by Frank J. Jirka, Jr., M. D., Presi- 
dent, American Medical Association. 

Recognition of AMA-ERF Grants to the 
We9t Virginia University and Marshall 
University Schools of Medicine. 

4:00 — Pre-Convention Board Meeting, Mrs. Richard 
S. Kerr, President, presiding (Fillmore- 
Van Buren Rooms). 

FRIDAY MORNING 
August 26 

9:00-4:00 — Registration, Lower Lobby. 

8:00— Past Presidents’ Breakfast, Mrs. Logan W. 

Hovis, Immediate Past President, presid- 
ing (Virginia Room). 

9:30 — Formal Opening of the Convention, Mrs. 

Richard S. Kerr, President, presiding 
(Fillmore-Van Buren Rooms). 

Invocation, Pledge of Loyalty and Pledge 
to Flag. 

In Memoriam — Mrs. G. A. Shawkey. 

Introduction of Honored Guests. 

Presentation of Harry Shannon, M. D., 
President, West Virginia State Medical 
Association. 

Introduction of Convention Chairman — 
Mrs. Logan W. Hovis. 

Roll Call of Delegates — Mrs. Charles C. 
Weise, Recording Secretary. 

Declaration of a Quorum — Mrs. J. L. Man- 
gus, Parliamentarian. 


Keynote Address — Mrs. John G. Bates, 
President, American Medical Association 
Auxiliary. 

Credentials and Registration — Mrs. Wilson 
P. Smith. 

Convention Rules of Order — Mrs. J. L. 
Mangus, Parliamentarian. 

Report of the 1982 Convention Reading 
Committee. 

Treasurer’s Report — Mrs. Harvey Reisen- 
weber. 

Recommendations from Pre - Convention 
Board Meeting. 

New Business. 

Report of the 1983 Nominating Committee, 
First Reading — Mrs. Logan W. Hovis. 

Election of the 1984 Nominating Commit- 
tee. 

Reports of Officers and Chairmen of Stand- 
ing Committees. (Those published in the 
Annual Reports Book will not be read.) 

Presentation of Regional Directors (and 
two-minute reports by county presi- 
dents ) : 

Northern Region — Mrs. A. S. Licata. 

Eastern Region — Mrs. Thomas W. 
Crosby. 

Western Region — Mrs. Mario Cardenas. 

Southern Region — Mrs. William M. 
Jennings. 

Central Region — Mrs. Jose M. Serrato. 
Announcements. 

Door Prizes — Mrs. Frank J. Holroyd. 

Recess. 

FRIDAY AFTERNOON 

Bridge (Trellis Lobby). Host Auxiliary, 
Eastern Panhandle, Mrs. Harvey D. 
Reisenweber. 

Golf. Host Auxiliary, Kanawha County, 
Mrs. John B. Markey. 

Tennis. Host Auxiliary, Raleigh County, 
Mrs. Prospero B. Gogo. 

(Times to be announced). 

SATURDAY MORNING 
August 27 

9:00-10:00 — Registration, Lower Lobby. 

9:00 — Second General Session, Mrs. Richard S. Kerr, 
President, presiding (Fillmore-Van Buren 
Rooms) . 

Introduction of Honored Guests. 


August, 1983, Vol. 79, No. 8 


183 


Roll Call of Delegates — Mrs. Charles C. 
Weise. 

Declaration of a Quorum — Mrs. J. L. Man- 
gus, Parliamentarian. 

Address — Mrs. William D. Hughes, Presi- 
dent, Southern Medical Association Aux- 
iliary. 

Convention Announcements — Mrs. Logan 

W. Hovis. 

Credentials and Registration — Mrs. Wilson 
P. Smith. 

Presentation of AMA-ERF Awards — Mrs. 
Herman Fischer, Chairman. Recognition 
of AMA-ERF Grants to the West Virginia 
University and Marshall University 
Schools of Medicine. 

Unfinished Business. 

Report of the 1983 Nominating Committee, 
Second Reading — Mrs. Logan W. Hovis. 

Election of Officers. 

Installation of Officers — Mrs. John G. 
Bates, President, American Medical Asso- 
ciation Auxiliary. 

Presentation of President’s Pin and Gavel, 
Mrs. Richard S. Kerr. 

Presentation of Past President’s Pin, Mrs. 
Logan W. Hovis. 


Inaugural Address — Mrs. T. Keith Edwards. 
Announcements. 

Door Prizes. 

Adjournment. 

11:00 — Post-Convention Board Meeting — Mrs. T. 

Keith Edwards, President, presiding (Fill- 
more-Van Bureau Rooms). 

SATURDAY AFTERNOON 


Presidential Address: Harry Shannon, 

M. D. 

Installation of Carl R. Adkins, M. D., 
Fayetteville, as 1983-84 President of the 
West Virginia State Medical Association. 

(Auxiliary members are invited and urged 
to attend). 

SATURDAY EVENING 

7:00 — Reception for State Medical Association mem- 
bers and guests (Chesapeake Terrace). 


8:00 — Dinner honoring officers of the West Virginia 
State Medical Association and the Aux- 
iliary (Chesapeake Hall). 


3:00 — Second and Final Session of the House of 
Delegates, West Virginia State Medical 
Association (Chesapeake Hall). 


184 


The West Virginia Medical Journal 


SCIENTIFIC EXHIBITS 


AMERICAN DIABETES ASSOCIATION, 
WEST VIRGINIA AFFILIATE, INC. 

“DIABETES.” Information on the work and goals 
of the group. 

Mike Murray, Affiliate member, and Douglas L. 
Jones, M. D., member, Board of Directors. 

BUREAU OF VENEREAL DISEASE CONTROL, 
WEST VIRGINIA STATE HEALTH DEPARTMENT 

“SEXUALLY TRANSMITTED DISEASES.” The 
two-panel display features one of the prominent 
sexually transmitted diseases. Current STD man- 
agement materials are available for pick-up by 
medical professionals. In addition, representatives 
from the West Virginia Venereal Disease Program 
will be manning the exhibit to discuss the state pro- 
gram and address other inquiries concerning the 
STDs. 

Ronald Bryant, Director, Venereal Disease Pro- 
gram, and Gregory Moore and Alan Bernstein, 
Venereal Disease Field Representatives. 

CHARLESTON AREA MEDICAL CENTER AND 

AUXILIARY TO CAMC MEMORIAL DIVISION 

“CAMC EXHIBIT.” The exhibit will contain 
CAMC educational and informational materials, in- 
cluding copies of a physician’s referral brochure, 
photographs of CAMC, and a slide/tape show on 
the medical center. 

Joseph T. Skaggs, M. D., Director of Medical 
Affairs; and William B. Ferrell, Assistant to Execu- 
tive Vice President. 

“TEL-MED” (AUXILIARY). Tel-Med, a free 
health information program, is a library of taped 
telephone messages on a variety of health and 
health-related subjects that have been approved and 
endorsed by the CAMC medical staff and Kanawha 
Medical Society. To use Tel-Med, dial the local 
number, 343-4400 (Charleston area) or the toll-free 
number outside of Charleston, 1-800-352-6510, and 
request the tape of your choice. Operating hours are 
from 9 A. M. to 8 P. M. six days a week, and from 
1 to 4 P. M. on Sundays and holidays. 

Frances McMillan, Health Education Chairman. 

DEPARTMENT OF MEDICINE, MARSHALL 
UNIVERSITY SCHOOL OF MEDICINE 

“IMPACT OF VIRAL RESPIRATORY DISEASES 
ON INFANTS AND YOUNG CHILDREN IN A 
RURAL AND SUBURBAN AREA OF SOUTHERN 
WEST VIRGINIA.” Acute viral respiratory disease 
occurring in children in Huntington, West Virginia 
(urban children), or in the hollows surrounding 
Huntington (rural children) was evaluated from 
September, 1978, through March, 1980. Epidemics 
of illnesses occurred simultaneously in the urban 
and rural groups. Among both the urban and rural 


ambulatory children, adenoviruses were the most 
common viruses isolated, and respiratory syncytial 
virus was the second most common viral pathogen 
isolated. Among the urban and rural hospitalized 
children, respiratory syncytial virus was the most 
common virus isolated. The risk of hospitalization 
because of respiratory disease was found to be one 
in every 20 children during the first four years of 
life, and the estimated risk of hospitalization be- 
cause of respiratory syncytial virus infection was 
one in 30. 

Maurice A. Mufson, M. D., Chairman. 

DISABILITY DETERMINATION SERVICE, 
WEST VIRGINIA DIVISION OF 
VOCATIONAL REHABILITATION 

“EVALUATION OF DISABILITY FOR SOCIAL 
SECURITY: HEMATOLOGY/ONCOLOGY, PE- 

DIATRICS AND ORTHOPEDICS.” Three board 
certified physicians wall present video tapes on 
difficult aspects of reporting for independent medi- 
cal assessment: Hematology /Oncology, A. Rafael 

Gomez, M. D., Charleston; Pediatrics, Marcel G. 
Lambrechts, M. D., Charleston, and Orthopedics, 
Robert W. Lowe, M. D., Huntington. 

These presentations also should aid attending 
physicians in preparing their abstracts for Social 
Security. 

David H. Cleland, Medical Relations Officer. 

FAMILY MEDICINE FOUNDATION OF 
WEST VIRGINIA 

(WEST VIRGINIA CHAPTER, AMERICAN 

ACADEMY OF FAMILY PHYSICIANS) 

“FUND RAISER— SEIGLE PARKS, M. D.” The 
Foundation will have on display three paintings by 
Seigle Parks, M. D., one of our family physicians. 
Doctor Parks donated these paintings for a fund 
raiser to benefit the Foundation. Please stop by our 
exhibit where these paintings will be on display. 
We also will have information on the long-term and 
short-term goals of the Foundation. 

Robert D. Hess, M. D., President; Thomas P. Long, 
M. D., Trustee, and Chris Ferrell. 

NATIONWIDE INSURANCE— MEDICARE 

“MEDICARE OPERATIONS.” Nationwide invites 
you to stop by and discuss your Medicare problems. 
Find out about CPT-4 coding and our electronic 
media claims billing available to your offices. Learn 
how you can receive payments faster. 

James A. Cuppy, Electronic Media Claims Man- 
ager; James B. Irwin, Field Service Manager, and 
Betty Rickenbacker, West Virginia Field Manager. 

SOUTHERN MEDICAL ASSOCIATION 

“SOUTHERN MEDICAL ASSOCIATION.” South- 
ern Medical will have information available on the 


August, 1983, Vol. 79, No. 8 


185 


advantages of membership such as continuing medi- 
cal education-Dial Access, regional postgraduate 
conferences, leadership seminars, medical malprac- 
tice seminars, the annual scientific assembly, and the 
Southern Medical Journal. Also available will be 
material on financial benefits to members such as 
the IRA, Keogh Plan, retirement and insurance 
programs, research project fund, and loans and 
scholarships. 

Robert P. Mosca, Director, Member Services, and 
Marc B. Wilson, Sales Coordinator. 

STATE MEDICAL ASSOCIATION’S GROUP 
INSURANCE AND PROFESSIONAL 
LIABILITY PLANS 

McDonough Caperton Shepherd Group, managing 
general agent of the State Medical Association’s 
group insurance and professional liability plans, will 
have on hand information describing each of the 
programs officially endorsed by the Association. 
Representatives also will be available to answer 
questions about the plans available. 

Mike Costello and Tom Auman, representatives. 

JOHN TAYLOR, M. D. 

“MANAGEMENT OF RECURRENT BASAL CELL 
EPITHELIOMA.” Some aspects of the etiology, 
morphology and photobiology of basal cell carci- 
nomas are treated. A discussion concerning the dif- 
ferent treatment modalities available is given and 
the advantages and disadvantages of each pointed 
out. Metastasizing basal cell carcinoma is discussed. 
Three cases of multiply recurrent basal cell carci- 
noma causing extensive debility and multiple 
ablative attempts are demonstrated. A recommenda- 
tion for definitive surgical excision utilizing either 
frozen section control or the Mohs technique is 
made, particularly in the recurrent lesions or those 
of a morpheaform or ulcerative invasive growth 
pattern. 

John Taylor, M. D., Bluefield, West Virginia. 

U. S. ARMY MEDICAL DEPARTMENT 

“U. S. ARMY MEDICAL DEPARTMENT.” Career 
opportunities as a member of the Army Medical 
Department, U. S. Army Reserve. 

Major James E. Kuza and Major Sheila Bowman, 
USAR AMEDD Procurement Counselors, and Cap- 
tain David Royer, USA AMEDD Procurement Coun- 
selor. 

U. S. NAVY RECRUITING DISTRICT, 
LOUISVILLE, KENTUCKY 

“COMPUTER-ASSISTED MEDICAL DIAGNOSIS 
OF ABDOMINAL PAIN.” We will present a video- 
tape demonstration of our system for computer- 
assisted medical diagnosis of abdominal pain. The 
system currently is undergoing sea trials aboard 
approximately 100 submarines. 

HMC William Brandshagen, USN, and HM1 Ken 
Devore, USN. 


WEST VIRGINIA DEPARTMENT OF HEALTH 

“YOUR LOCAL HEALTH DEPARTMENT.” This 
is a display of local health department activities and 
services as well as a highlight of local health officers 
in each county. 

L. Clark Hansbarger, M. D., Director. 

WEST VIRGINIA DIVISION OF VOCATIONAL 
REHABILITATION AND WEST VIRGINIA 
WORKERS’ COMPENSATION FUND 

“JOINT VOCATIONAL REHABILITATION- 
WORKERS’ COMPENSATION PROGRAM.” The 
exhibit features a three-screen audiovisual presen- 
tation that describes the program for persons injured 
on the job, a program operated jointly by the West 
Virginia Division of Vocational Rehabilitation and 
the West Virginia Workers’ Compensation Fund. 
Side panels of the exhibit treat in detail the services 
provided by the two agencies. 

Samuel B. Mann, Lewisburg District Supervisor, 
DVR; and Thomas Lyttleton, Rehabilitation Coun- 
selor, Lewisburg Office, DVR (Workers’ Compensa- 
tion representatives to be named). 

WEST VIRGINIA MEDICAL INSTITUTE, INC. 

“WEST VIRGINIA MEDICAL INSTITUTE, INC. 
— DRG DISPLAY.” The exhibit will display infor- 
mation on classification by Diagnosis Related Groups 
(DRGs). An on-line CRT terminal will be available 
for accessing selected DRG data from WVMI’s data 
base for Medicare and Medicaid patients. In addi- 
tion, samples of hard-copy DRG reports by hospital 
and physician will be available. WVMI staff and 
physician committee members will attend the dis- 
play. 

WEST VIRGINIA PERINATAL ASSOCIATION 

“WEST VIRGINIA PERINATAL ASSOCIATION.” 
This exhibit will announce the formation of a new 
organization which will improve health care to 
pregnant women and newborns. The organization 
is multidisciplinary, including obstetricians, pedia- 
tricians and family practitioners. 

Martha D. Mullett, M. D., President. 

WEST VIRGINIA 

PHYSICAL THERAPY ASSOCIATION 

“PEDIATRIC REHABILITATION: CURRENT 

CONCEPTS OF CARE.” The display is designed to 
depict current concepts in pediatric rehabilitation. 
Emphasis is on informing physicians of the changing 
roles and responsibilities of the physical therapy 
practitioner. 

Dee-dee Daniel and Hugh Murray, physical ther- 
apists. 

WEST VIRGINIA POISON CENTER 

“GET TO KNOW ABOUT POISONS.” Describes 
the various functions of, and materials available to, 
the professional and lay public through the West 
Virginia Poison System. 

Terri DeFazio, Susie Aston, Sheila Totten, Donna 
Samples, and Cynthia Tennant, poison specialists. 


186 


The West Virginia Medical Journal 


WEST VIRGINIA UNIVERSITY HOSPITAL 

“WEST VIRGINIA UNIVERSITY HOSPITAL 
TODAY!” The exhibit illustrates some of the tech- 
nologies available to referring physicians and their 
patients. Vascular specialists screen patients with 
noninvasive procedures for hemodynamically signifi- 
cant carotid artery stenosis. Angioplasty to open 
narrowed or occluded blood vessels is the cardi- 
ologist’s newest tool. Surgical specialists use lasers 
for cutting and vaporization of tissue. Neonatal life 
support continues to increase in sophistication. 1-125 
implantations are used to treat cancer of the prostate 
and pancreas. Radiologists enjoy more refined 
images of the malfunctioning kidney with per- 
cutaneous procedures. Spend a few minutes to see 
“West Virginia University Hospital Today!” 

David Fine, Administrator; Andrew Lasser, Asso- 
ciate Administrator, and Virginia Nugent, Adminis- 
trative Assistant. 


WEST VIRGINIA UNIVERSITY 
SCHOOL OF MEDICINE 

“WEST VIRGINIA UNIVERSITY SCHOOL OF 
MEDICINE REACHES OUT.” Because the WVU 
School of Medicine exists “for the sake of West 
Virginians,” every department is involved in activ- 
ities which purposely extend beyond the campus 
boundaries. This exhibit portrays many examples 
of programs designed to reach out and make a direct, 
practical difference for individuals and communities 
across West Virginia. Examples range from edu- 
cating MDs who will establish their practice in West 
Virginia communities, to hearing clinics for the 
elderly, to genetics screening programs for pros- 
pective parents, and to providing orthopedic con- 
sultation at a home for handicapped children. 

Robert L. Smith, M. D., Assistant Dean, School of 
Medicine; Linda C. Morningstar, Consultant, School 
of Medicine, and Robert E. Kristofco, Manager, 
CME, School of Medicine. 


August, 1983, Vol. 79, No. 8 


187 


ANNUAL REPORTS 


Committee on Insurance 

The year 1983 marks the 35th of the West 
Virginia State Medical Association’s Insurance 
Program. Since its establishment in 1948, 
hundreds of doctors throughout West Virginia 
have been the recipients of benefits under this 
program. 

Throughout the years, each plan has been 
continuously upgraded and new plans added to 
meet the needs of our members. Two examples 
would be the following: 

Major Medical Plan — As reported last year, 
the Committee approved our insurance ad- 
ministrator’s recommendation to change in- 
surance companies and expand benefits under 
this plan. As a result, the number of partici- 
pants lias increased from 206 to 328. 

Life Plan — Within the past year, partici- 
pation in this plan lias increased by 25 per 
cent. 

In addition to tbe above, our members con- 
tinue to avail themselves of the following plans 
which comprise our total insurance portfolio: 
Income Protection ( Disability ) 

Accidental Death & Dismemberment 
Hospital Indemnity Plan 
Office Overhead Expense 
Coordinated Pension Services 
Professional Liability Insurance (separate 
report attached ) 

Summarization 

Our total insurance program available to mem- 
bers and their employees continues to provide a 
very viable benefit for members of tbe West Vir- 
ginia State Medical Association. Since 1948, it 
has stood the test of time with the continuous 
support of our members and the professional 
competence of our administrator. 


Professional Liability 

The Professional Liability Insurance Program 
is a combination of effort on the part of the 
M edical Association, CNA Insurance Company 
and McDonough Caperton Shepherd Association 
Group to provide a first-rate professional liability 
program for eligible Association members. 

Common representation of all physicians in 
the program by the Managing General Agent - 


the role occupied by McDonough Caperton Shep- 
herd — is important for program responsiveness. 
Provision exists for West Virginia physicians to 
be important contributors in claim review and 
peer review. Physicians are given an opportunity 
to be heard concerning any element of the pro- 
gram. 

Several accomplishments for the program 
need to be reported: 

1. A new computer program that rates and 
prints tbe policies in Charleston is func- 
tional. 

2. A new computer claim program that pro- 
vides statistical data for loss control efforts 
now exists. 

3. The District Claim Review Panels are 
functional. 

4. The Professional Evaluation Committee 
has provided input in several areas of con- 
cern. 

5. Several loss control programs have been 
presented to medical groups. 

The Association-endorsed program is currently 
in sound condition. This will continue as long 
as physicians work to support the program. This 
includes providing medical input into the pro- 
cess of selecting insured physicians. The Associ- 
ation wants the selection process to be fair, but 
feels strongly that physicians with repeated poor 
loss experience or evidence of improper practices 
should not be insured in the program. The pro- 
gram must remain financially healthy. This is 
an area in which strength in numbers is im- 
portant. We encourage all members to review 
the CNA program and see the commitment being 
made to West Virginia Medicine. 

Respectfully submitted, 

Jack Leckie, M. D., Chairman 


Committee on Medical Education 
and Hospitals 

The past year (September to August) has 
produced considerable activity on the part of the 
West Virginia State Medical Association’s Com- 
mittee on Medical Education and Hospitals. 

Since the early 1970s, this Committee has 
been the unit to execute Association responsi- 
bility for the accreditation of intrastate con- 


188 


The West Virginia Medical Journal 


tinuing medical education programs, primarily 
at community hospitals. In its role, the Associa- 
tion has been an arm of various national organ- 
izations, including the American Medical As- 
sociation; the Liaison Committee on Continuing 
Medical Education, and now the multi-organiza- 
tion Accreditation Council for Continuing Medi- 
cal Education. 

This past year has seen Committee representa- 
tives and members of the Association staff re- 
survey for continued accreditation CME pro- 
grams at Charleston Area Medical Center, 
Broaddus Hospital-Myers Clinic in Philippi, and 
the West Virginia Academy of Ophthalmology. 
In each instance, varying periods of additional 
accreditation resulted. 

Surveyed as a new applicant for accreditation 
was City Hospital of Martinsburg — given initial, 
provisional approval. Being processed as this 
report was prepared was another new application 
from United Hospital Center in Clarksburg, 
while the year also will bring resurveys at Jack- 
son Ceneral Hospital in Ripley, Veterans Ad- 
ministration Center in Martinsburg, Ohio Valley 
Medical Center /Wheeling Hospital, St. Francis 
Hospital in Charleston and Northern Panhandle 
Mental Health Center in Wheeling. 

New Surveys 

New surveys usually are conducted by an on- 
site team of two or three persons, with one mem- 
ber an Association staff representative, after 
completion by the organization being surveyed 
of a detailed questionnaire setting forth CME 
budgets, assigned administrative and education 
responsibilities, methods for evaluation of course 
material, etc. The new surveys are always con- 
ducted while a CME activity is in session. 

A similar questionnaire is required in a resur- 
vey, usually involving a one-physician site visit 
in which, among other things, a careful review 
is made of progress — including correction of 
previously noted defects — made in the preceding 
accreditation period. 

First a subcommittee and then the full Com- 
mittee on Medical Education and Hospitals are 
involved in a review of accreditation team find- 
ings and recommendations before the institutions 
or organizations are advised of the action taken. 
Accreditation can and should mean many things 
to facilities and physicians, including approval 
of CME programs for Category 1 credit toward 
the AMA Physician’s Recognition Award. 

This past year also has brought detailed review 
and comment by key Committee representatives, 
and the Association staff, on an all-but-final, and 


extensive, revision of the national essentials for 
accreditation of those institutions sponsoring 
CME programs. Essentials used in West Virginia 
are consistent with — and in some instances go 
a bit beyond — the national standards. 

Also revised and strengthened this year has 
been the ACCME-developed protocol for recogni- 
tion of state medical associations and/or 
societies as accrediting agencies for intrastate 
CME. The West Virginia State Medical Associa- 
tion can look forward in the near future to a 
visit from an ACCME team to determine how 
the Association is meeting the protocol criteria. 

Pre-Survey Questionnaire 

Such a visit will be preceded by a pre-survey 
questionnaire which must be completed and re- 
turned in time for full review by an ACCME 
representative prior to the actual site visit. 

Working relationships with the national 
ACCME office in the Chicago area have been 
most satisfactory and productive. The Associa- 
tion was charged by its leadership, in the early 
1970s, with developing a fair but demanding 
program for intrastate accreditation. 

The road, over the years, has not been with- 
out growth problems and rough spots. In some 
instances, accreditation of institutions initially 
has been denied, or provisional approval re- 
moved. But the overall results appear solid and 
effective. 

The commitment to the program is, if any- 
thing, stronger than ever, particularly in the light 
of the new essentials and protocol. That leads 
to a further confidence that the physician, staff 
and other investment not only is justified, hut 
ranks as one of the most valuable services the 
Association can provide. 

Respectfully submitted, 

William 0. McMillan, Jr., M. D., Chairman 


Cancer Committee 

The Cancer Committee met at the State Medi- 
cal Association’s Annual Meeting at the Green- 
brier on August 27, 1982, and again in Charles- 
ton on January 23, 1983, during the 16th 
Mid-Winter Clinical Conference. 

The State Cancer Registry was explored again, 
and again recommended for re-establishment. It 
was noted that cancer has been designated as a 
reportable disease. 

The American Cancer Society’s Caring and 
Sharing and Cancer Prevention programs con- 


August, 1983, Vol. 79, No. 8 


189 


tinue to be successful throughout the state, and 
are endorsed by the Committee. 

The Community Clinical Oncology Program 
Grant for West Virginia was submitted. Dr. 
Steven J. Jubelirer, the principal investigator at 
Charleston Division of West Virginia University 
Medical Center, has been notified of its approval 
and funding. 

Fifteen new Cancer Liaison members of the 
American College of Surgeons were appointed 
by Doctor Watne, and others will continue to he 
appointed. 

Respectfully submitted, 

Alvin L. Watne, M. D., Chairman 


Committee on Venereal Disease 

The incidence of venereal disease in West 
Virginia for calendar year 1982 totalled 3,211 
cases occurring in every county of the state. 
Case-related data revealed a level of 160 infec- 
tions per 100,000. Gonorrhea represented 2,609 
cases or a rate of 130 per 100,000. The inci- 
dence of venereal disease in West Virginia is 
most evident among the age group 15-29, which 
reportedly represented 80 per cent of the 
morbidity. 

Other sexually transmitted diseases that are 
being observed frequently by practitioners are 


non-gonococcal urethritis/vaginitis and herpes 
simplex Type II. While NGU can be and is 
easily treatable, herpes is not. Increased inci- 
dence of these diseases as well as acquired 
immune deficiency syndrome (AIDS), which 
seems to be most prevalent nationally in the gay 
community but certainly involves other social 
and health-problem groups, may be a basis for 
future consideration to make these diseases 
reportable in West Virginia. 

The statewide culture screening activity 
directed toward early detection of asymptomatic 
female gonorrhea victims provided 54,950 ex- 
aminations in 1981-82; 804 young women of 
child-bearing age were found to have laboratory 
evidence of the disease. With this in mind, 
medical providers should consider strongly per- 
forming routine cervical gonorrhea cultures on 
females 15-40 years of age when doing pelvic 
workups, particularly in all prenatal patients both 
early as well as late in their pregnancy. 

Inquiries regarding the medical/epidemiologic 
management of the sexually transmitted diseases 
can be addressed through a toll-free line within 
the state venereal disease program, 1-800-642- 
8244, or by calling your local health department. 

Respectfully submitted, 

Page H. Seekford, M. D., Chairman 


190 


The West Virginia Medical Journal 


WHY BMW CHOSE 
TO CHANGE THE 
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ROUTE 60, WEST ST. ALBANS 722-4900 


WVU Medical Center 
-News— 


Compiled from material furnished by the Medical Center 
News Service, Morgantown, W. Va. 


School Of Medicine Faculty 
Promotions Announced 

Twenty-five faculty members in the School of 
Medicine have been awarded promotions. 

John E. Jones, WVU Vice-President for JJealth 
Sciences, announced the promotions which were 
approved by the West Virginia Board of Regents 
along with 22 others from the University Medical 
Center's three other schools. 

Each school makes performance reviews 
based on teaching, research and service before 
the promotions recommendations are sent to the 
hoard. 

Those promoted, effective July 1, in the School 
of Medicine were: 

Soad Bekheit, Professor, Medicine; J. David 
Blaha, Associate Professor, Orthopedic Surgery; 
Eric Brestel, Associate Professor, Medicine; 
David B. Burr, Associate Professor, Anatomy; 
J. Richard Casuccio, Assistant Professor, Oto- 
laryngology; Paul L. Clausell, Associate Profes- 
sor, Behavioral Medicine and Psychiatry; Joseph 
Fontana, Associate Professor, Medicine; David 
F. Graf, Associate Professor, Anesthesiology; 
Marybeth JJarris, Assistant Professor, Physical 
Therapy; Richard J. Head, Associate Professor, 
Pharmacology and Toxicology; Ellen Hrabovsky, 
Professor, Surgery; Michael Johnson, Associate 
Professor, Physiology. 

Steven Jubelirer, Associate Professor, Medi- 
cine; Arthur E. Kelley, Associate Professor, Be- 
havioral Medicine and Psychiatry; Darshan S. 
Kelley, Research Assistant Professor, Biochemi- 
stry; Richard E. Klabunde, Associate Professor, 
Physiology; Rolf F. Kletziem, Professor, Bio- 
chemistry; William W. Orr, Associate Professor, 
Behavioral Medicine and Psychiatry; John 
Petronis, Professor, Physical Therapy; Patrick 
Robinson, Associate Professor, Medicine; Joan 
T. Robison, Associate Professor, Behavioral 
Medicine and Psychiatry; Jamshid Tehranzadeh, 
Associate Professor, Radiology; George Try- 



fiates, Professor, Biochemistry; Irma EHlrich. 
Professor, Medicine; Mary J. Wimmer, Associ- 
ate Professor, Biochemistry. 


Use Of Laser Unblocks Airway 
In Lung Cancer Patient 

Uaser treatment to unblock the right main air- 
way of a patient suffering from lung cancer has 
been used at WVU Medical Center with good 
results. 

Drs. Harakh Dedhia and N. LeRoy Lapp, co- 
investigators, said that to their knowledge it was 
the first use in West Virginia of Nd-YAG laser 
phototherapy in lung cancer. 

Doctor Dedhia is Associate Professor of 
Anesthesiology and Medicine, and Doctor Lapp 
is Professor of Medicine and Chief of the 
Pulmonary Medicine Section. 

They said the patient had complete blockage 
of the right main bronchus where it joins the 
windpipe, and that the radiotherapists didn’t 
want to treat the lung cancer because of the 
obstruction. 

Faced Dilemma 

“They felt they would either give too heavy 
a dose of radiation to the collapsed lung or would 
induce infection behind the obstruction, and 
she would be worse off than she was,” Doctor 
Lapp explained. 

“So they asked us to see if we could open 
that passage and give her some air in the right 
lung, which we were able to do in three treat- 
ments. 

“After each treatment, we gave the patient a 
period of time to heal. When we looked at the 
treated area there was evidence of sloughing off 
of all black, dead tissue, and there was a smooth 
membrane covering the area, so there was some 
healing which had occurred as well.” 

Doctor Lapp cautioned, however, that the 
treatment is experimental and is limited to use 
in selected patients for whom surgery is not indi- 
cated. 


The West Virginia Medical Journal 



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Third-Party News, Views 
and Program Concerns 



FTC Okays Preferred Provider 
Group In New Jersey 

In its first pronouncement on the subject, the 
Federal Trade Commission has given its tenta- 
tive blessing to a proposed preferred provider 
organization ( PPO ) in New Jersey. 

The advisory does not have the weight of law, 
and is not binding on courts, though courts do 
consider advisory opinions. It could be revoked 
at any time. In addition. PPOs have taken many 
forms, and clearance for the New Jersey PPO is 
not applicable to other types of PPOs. 

The advisory is significant, however, in that it 
represents the FTC’s first step into the cloudy 
issues surrounding the PPO concept, the Ameri- 
can Medical Association commented. 

The advisory that was issued went to Health 
Care Management Associates (HCMA), a 
Moorestown, New Jersey, consulting firm that is 
developing a PPO known as the Cooperating 
Provider Program. It said the FTC does not be- 
lieve HCMA’s proposed PPO would violate anti- 
trust law. 

HCMA Is Brokering Agent 

HCMA sees itself as a brokering agent in the 
arrangement. It would contract with up to 15 
per cent of individual physicians, oral surgeons, 
podiatrists and psychologists in three counties 
to provide care to patients covered under the 
plans of insurers or companies that sign up with 
HCMA. 

In its advisory letter to HCMA, the FTC noted 
that “no actively practicing provider, hospital, or 
payer has any direct or indirect financial, con- 
trolling, or non-controlling interest in HCMA.” 
It also carefully spelled out that the financial ar- 
rangements are to be between HCMA and each 
individual physician. 

Those, according to FTC official Walter Wins- 
low, are two aspects of HCMA’s plan that set it 
apart from many other PPOs. The latter is 
particularly significant because it distinguished 
HCMA from the Maricopa Foundation in 
Arizona, which the Supreme Court ruled had 
engaged in price fixing by agreeing jointly on 
the maximum fees its members would seek. 


FTC Also Approves Review 
Of Private Programs 

The FTC also gave a Rhode Island Profes- 
sional Standards Review Organization the go- 
ahead for its plan to review the medical necessity 
of care provided to private employers’ health 
benefits programs. 

The PSRO had asked the FTC in January for 
an advisory opinion on its plan to conduct pre- 
admission and concurrent reviews of private pa- 
tients, to recommend appropriate lengths of hos- 
pital stays and to conduct quality review studies. 
Its recommendations are not binding on the 
companies, and no fee reviews would be con- 
ducted under the program. 


4 Baby Doe’ Rule Springs 
Back To Life 

The U. S. Department of Health and Human 
Services has proposed a new version of the con- 
troversial “Baby Doe” rule requiring hospitals 
and clinics to post, notices publicizing a 24-hour 
hotline to be used in cases of suspected neglect. 

The original regulation was struck down in 
federal court last May. 

The procedure, rather than the substance of 
the rule, is changed. It still contains the re- 
quirement to post notices listing the hotline num- 
ber. But instead of requiring the posting of the 
notice in delivery, maternity, and intensive care 
wards, it requires that the notice must be posted 
in nursing stations. The new rule also will allow 
a longer public comment period. 

The rule’s long preamble and appendix specify 
that federal law “does not require the imposition 
of futile therapies which merely temporarily pro- 
long the process of dying of an infant born 
terminally ill.” The rule also attempts to define 
the term “handicap” as disorders such as “mental 
retardation, blindness, paralysis, deafness, or lack 
of limbs.” 

“Any judgment that a person is not worthy of 
treatment due to such handicap is not ... a 
medical judgment, even if made by doctors . . . ,” 
the rule says. 


xiv 


The West Virginia Medical Journal 


Obituaries 


SANGA TANTULAVANICH, M. D. 

Dr. Sanga Tantulavanich. Welch internist, was 
drowned on April 2 after heavy seas capsized the 
boat in which he was a passenger in the Gulf of 
Thailand. 

Doctor Tantulavanich, 33, was one of eight 
persons drowned or originally missing in the 
accident; 22 others were rescued. The site was 
near the coastal city of Samut Prakan in 
Thailand. 

A native of Bangkok, Thailand, Doctor 
Tantulavanich was a member of the staff of 
Stevens Clinic Hospital in Welch. 

He was a member of the McDowell County 
Medical Society and the West Virginia State 
Medical Association. 


County Societies 


FAYETTE 

Dr. Sidney Richman of Hartford, Connecticut, 
was the guest speaker for the meeting of the 
Fayette County Medical Society on June 1 at 
Montgomery General Hospital. 

Doctor Richman’s topic was “The Use of 
Beta-Blockers in Hypertension.” He is a 
cardiologist and Associate Professor of Medi- 
cine at the University of Connecticut. — S. S. 
Maducdoc, Jr., M. D., Secretary-Treasurer. 


CHANGE OF ADDRESS 

Members of the West Virginia State Medical 
Association are requested to notify the headquarters 
offices promptly concerning any change in address. 
The 1984 Roster of Members will be prepared and 
placed in the mails shortly after the first of the year 
and we would very much like for your correct ad- 
dress to appear in same. If applicable, to comply 
with recent U. S. Postal Service regulations, please 
include your P. O. Box number with zip code. 
Changes should be mailed to Box 1031, Charleston, 
West Virginia 25324. 


The 

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For information, contact: 

Continuing Education 
The Milton S. Hers hey 
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(717) 534-6495 


August, 1983, Vol. 79, No. 8 


xv 




Professional 

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Reprinted from The West Virginia Medical Journal, September 1981 



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• A consent to settle provision for doctors covered under the plan. 

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The West Virginia Hedical Journal 


Vol. 79, No. 9 


September, 1983 


Public Health Legacy of the Vietnam War: 
Post-Traumatic Stress Disorder and Implications 

for Appalachians* 


DANIEL SUMROK, B. A. 

Marshall University School of Medicine Student, 
Class of 1984, Huntington 

STEVEN L. GILES, Ph.D. 

Team Leader, 

Huntington Veterans Center 

MILDRED MITCHELL-BATEMAN, M. D. 
Professor and Former Chairman of Psychiatry, 
Marshall University School of Medicine 


Suicide ; child and spouse abuse ; divorce; 
alcoholism and drug abuse; jail terms, and 
psychiatric and physical maladies are the public 
health legacy of the Vietnam War. Complex 
interacting factors account for the fact that West 
Virginians suffered the highest casualty rates 
during the war. It is conservatively estimated 
that 7,000 West Virginians continue to suffer 
from Post-Traumatic Stress Disorder ( PTSD ) in 
the aftermath of the war. The temptation has 
been for Americans to want to forget our longest 
war — one that ue lost. It is a painful story. 

If providers of medical and health care are 
to intervene successfully in this mammoth public 
health problem, the dynamics of its development 
must be understood. 

Introduction 

'"pms paper is intended to explain the problems 
presently being experienced by some Viet- 
nam veterans. It is an attempt to heighten the 
awareness of primary care providers and their 
colleagues so that the public can be better served. 

“This paper was developed in conjunction with a special 
research project conducted through the Marshall Uni- 
versity School of Medicine’s Department of Psychiatry. 


Approximately 8.5 million individuals served 
in the military during the Vietnam era with 2.8 
million being assigned to Southeast Asia from 
1964 - 1973. Almost one million were engaged 
in active combat or w r ere exposed to hostile, 
life-threatening situations (President’s Commis- 
sion on Mental Health, 1978). There are 29,000 
Vietnam combat veterans in the state of West 
Virginia (Giles, 1981). A major problem has 
been to convince the public, both lay and profes- 
sional. that Vietnam veterans indeed experienced 
a war that was unique in its situations and 
stresses. The nature of the Vietnam struggle has 
presented a unique set of problems to those who 
experienced it. Herein, it is hoped that the 
reasons for the uniqueness, and as such, the toll 
exacted on our countrymen and their families 
and friends can be clarified. 

Just as defending our great nation is every- 
one’s responsibility, so is it everyone’s responsi- 
bility to recognize the defenders, their sacrifices, 
and provide them the sensitive treatment they 
need. 

Combat as Stress: 

A Review of the 

Development of Current Theory 

During World War I, specific clinical 
syndromes came to be associated with combat 
duty. Previously, such casualties had been dis- 
missed as being a result of cowardice and poor 
discipline. The concept evolved that the high 
pressure of exploding shells caused actual 
physiologic damage precipitating symptoms la- 
beled “shell shock.” By the end of the war, the 


September, 1983, Vol.. 79, No. 9 


191 


syndrome was being described as a “war 
neurosis” (Glass, 1969). As with any neurosis, 
the focus was that predisposing personality 
characteristics of the combatant were responsible 
for the reaction, rather than the traumatic ex- 
periences intrinsic to combat. 

In the early years of World War II, psychiatric 
casualties had increased by 300 per cent com- 
pared to World War I, even though preinduction 
psychiatric rejection rate was four times greater 
than World War I (Figley, 1978). At one point 
in the war, the number of men being discharged 
from service for psychiatric reasons actually 
exceeded the number of men being drafted 
( Tiffany /Allerton, 1967). 

Using the assumption that predispositional 
factors were the primary precipitant of combat 
psychological breakdown, it soon became appar- 
ent that not many soldiers would be immune. In 
fact, a 1944 Inspector General’s report con- 
cluded: “If screening is to weed out all those 
likely to develop a psychiatric disorder, then all 
should be weeded out.” The concept of war 
neurosis with an etiolgic basis on the pre-military 
history of combatant had outlived its usefulness. 
Hereafter, various intrinsic combat stresses were 
recognized as the basis of psychiatric decompen- 
sation (Figley, 1978). 

The lessons of World War II were well 
learned. Due to the efforts of military psychi- 
atrist Alber Glass (1954), combatants who suf- 
fered breakdown in Korea were dealt with in a 
very situational and usually on-site manner, with 
the expectation of speedy return to the combat 
unit. The results of the new perspective had 
immediate payoffs. During World War 11, 23 
per cent of casualties evacuated suffered from a 
psychiatric malady whereas only 6 per cent of 
Korean War casualties were evacuated for 
psychiatric reasons (Bourne, 1970). 

Suprisingly, in the Vietnam War, battlefield 
psychological casualties evolved in a new and 
unexpected direction. What was expected via 
past war experience (and what was prepared 
for) did not materialize. Battlefield psycho- 
logical casualties were at an all time low of 1.2 
per cent (Bourne, 1970). At the time it was 
thought that the use of preventive measures 
learned in Korea and added situational manipu- 
lations (to be discussed later) had solved the 
ancient problem of combat breakdown. 

As the war continued for a number of years, 
some trends began to emerge. A previously 
obscure but well documented phenomenon of 
World War II began to be seen again. At the 
end of World War II, some men suffering from 


acute combat reaction, as well as their peers 
with no such symptoms, began to report common 
complaints, such as intense anxiety, battle 
dreams, depression, explosive agressive behavior, 
and problems with interpersonal relationships. 
These symptoms were found in five-year follow- 
up (Futterman and Pumpian-Mindlin, 1951) 
and 20-year follow-up studies (Archibald and 
Tuddenham, 1965). 

Again in Vietnam, both those who had suffered 
from acute combat reaction and others who did 
not began to claim these same symptoms long 
after leaving the combat situation. What was 
unusual compared to previous wars was the 
large number of veterans reporting these symp- 
toms. In previous wars, incidence of psychiatric 
casualties was observed to increase as intensity 
of the war increased, and correspondingly, the 
incidence decreased as the war intensity de- 
creased. During Vietnam the pattern of reported 
psychiatric casualties differed; as combat in- 
tensity increased, there was no corresponding 
increases in the casualty rate. It was not until 
the early 70s, as the war was winding down, that 
incidence of psychiatric disorders began to in- 


ii On state-by-state analysis , West Vir- 
ginians suffered the highest casualty rate 
in Vietnam ivith 85 men losing their life 
for every 100,000 males in the 1970 
census 


crease. By 1973, with the end of direct American 
troop involvement, the number of veterans pre- 
senting with neuropsychiatric disorders mush- 
roomed ( President’s Commission on Mental 
Health, 1978). 

During the 1970s, many civilian natural 
disasters had occurred (fires, earthquakes, plane 
crashes, etc. ) . The survivors of these catas- 
trophies presented with problems strikingly 
similar to those of Vietnam veterans. After 
much research (Figley, 1978) by various 
veterans’ task forces and recommendations by 
therapists involved with civilian post-traumatic 
problems, the Diagnostic and Statistical Manual 
III ( DSM III), published in 1980, included a 
new category: Post-Traumatic Stress Disorder 

(Acute, Chronic and/or Delayed). 

The acute subtype can be thought of as those 
disorders previously known as “shell shock” or 
“acute combat reaction.” As noted, the incidence 
of this acute type, due to behavioral manipula- 
tions and unique circumstances of the Vietnam 
War, was very low. The chronic or delayed sub- 


192 


The West Virginia Medical Journal 


types have, however, taken on special significance 
with their recognition in veterans of the Vietnam 
War. PTSD (Delayed or Chronic) manifests 
itself in various insidious processes, and often 
may have been diagnosed as an individual 
personality disorder. 

Features of Post-Traumatic Stress Disorder, 
Chronic or Delayed 

Characteristic symptoms follow a psycho- 
logically traumatic event outside the range of 
usual human experiences (DSM III, 1980). 
Simple bereavement, chronic illness, business 
losses or marital conflict are considered within 
the usual realm of experience unlike rape or 
assault, military combat, natural disasters, 
serious car or plane accidents, torture or concen- 
tration camps. 

PTSD can be variously expressed. Commonly 
the individual suffers intrusive, painful recollec- 
tions or nightmares during which the stressful 
event is re-experienced. Rarely, dissociative 
states, lasting minutes to hours or days, occur 
during which the individual relives, and behaves 
as if experiencing, the original stressful event. 
Diminished responsiveness to external events 
referred to as “emotional anesthesia” or “psychic 
numbing” commonly begins soon after the stres- 
sor event. PTSD victims complain of feeling 
detached or estranged from previously significant 
life experiences (DSM III, 1980). Problems with 
intimacy, tenderness and sexuality are common. 
In fact, the majority of veterans at the Hunting- 
ton Vet Center are experiencing marital diffi- 
culty (Giles, 1981). Many report this is a 
consequence of loss of affect, which they them- 
selves relate to Vietnam combat experience. 
Exaggerated startle response or hyperalertness 
due to hyperautonomia follow the stressor. 
Phobic avoidance of situations that remind 
victims of the stressor is common. Hot, humid 
weather, helicopter noise, open spaces in fields 
surrounded by thick vegetation and “annivers- 
ary” reactions have been reported to stimulate 
exacerbation of symptoms. Anxiety and depres- 
sion, explosive behavior with minimal or no 
provocation, inability to concentrate, and failing 
memory are all characteristic. Substance abuse 
and its milieu of accompanying complicating 
effects often develop. 

The Vietnam Experience as Predisposing to 
Post-Traumatic Stress Disorder 

Going into Vietnam, military planners used 
lessons of previous wars in an attempt to solve 
the huge problem of battlefield psychological 


breakdown. It was understood that men with the 
most combat exposure suffered the highest rate 
of breakdown. 

The result was the DERO$ system (date of 
expected return from overseas). All personnel 
knew upon leaving the United States when he or 
she would be rotated back stateside. All tours 
were 12 months except those for the Marines, 
who served 13 months. DEROS offered each 
individual a way out of the war other than as a 
physical or psychological casualty (Kormos, 
1978). The advantage of the system was clear. 
If the individual could hold together for the 
predesignated time period, the promise of state- 
side rotation would be a way for the combatant 
to leave the war behind. The disadvantages of 
DEROS were not immediately clear. DEROS 
became a very personal thing as each person 
rotated on his own with his own specific date. 
This meant that the Vietnam experience became, 
for each person, a solitary, individual episode. 
It was rare, after the first few years of the war, 
for entire units to be sent to the war zone simul- 
taneously. As Bourne noted (1970, p. 12), 
“The war becomes a highly individualized, 
encapsulated event for each man. His war begins 
the day he arrives in the country and ends the 
day he leaves.” Bourne further asserts (p. 42), 
“He feels no continuity with those who precede 
or follow him. He even feels apart from those 
who are with him but rotating on a different 
schedule.” 

Unit morale, cohesion and identification suf- 
fered tremendously (Kormos, 1978). Studies 
from past wars ( Grinker & Spiegel, 1945) point 
to unit integrity acting as a buffer for the indi- 
vidual against the overwhelming stresses of com- 
bat. World War II veterans commonly spent 
extended periods of weeks or months on “the 
long boat ride home.” The importance of this 
is that the World War II veterans, in the context 
of the unit, were able to work through especially 
troubling combat experiences that they had been 
through together. In contrast, the Vietnam 
veteran had a solitary plane ride home and a 
head full of grief, joy, confusion and conflict. 
Many went from firefight to southern California 
in a period of 36 hours. Most made it stateside 
in less than one week. 

For the Vietnam combatant the DEROS date 
became a fantasy that promised an end to all 
problems as he took the “freedom bird” state- 
side. In the “other world” context of Vietnam, 
individuals believed that neither they as indi- 
viduals, nor the United States as a society, had 
changed in their absence. Hundreds of thousands 


September, 1983, Vol. 79, No. 9 


193 


lived this daily fantasy as evidenced by the uni- 
versal popularity of “short-timers calendars.” 
“Short-timers” were GIs nearing an end of their 
Vietnam tour. The intricately designed calen- 
dars contained spaces for 365 days and they were 
openly displayed and cherished as “short time” 
approached. “Short-timers” were revered by 
their peers, and almost daily led their peers 
through fantasy ritual descriptions about how 
carefree life would be upon returning home. 
For the GJ who was struggling with psycho- 
logical breakdown due to the stresses of combat, 
the DEROS fantasy served as a major prophy- 
lactic to actual overt symptoms of acute combat 
reaction. The vast majority did hold on as evi- 
denced by low psychiatric casualty rates during 
the war (President’s Commission on Mental 
Health, 1978). 

Struggle to Hold on Difficult 

The struggle to hold on was difficult for most. 
Motivations that keep combatants fighting, unit 
esprit de corps, small group solidarity and an 
ideologic belief that this was the good and just 
fight were not present in Vietnam. Complete 
strangers, often GIs who were strangers to the 
speciality of the individual unit, were rotated 
in as others rotated out. Veterans who had 
reached a level of proficiency also had reached 
their DEROS date and were rotated. Green 

troops or “F.N.G.’s” ( new guys) with 

poorly developed skills took their places. “New 
guys” were avoided by seasoned troops until they 
had a couple of months of experience because 
no short-timer wanted to get killed by relying 
on an inexperienced “F.N.G.” It is obvious that 
endless arrivals and departures slashed unit 
culture and esprit. 

It was a rare occurrence that Vietnam veterans 
wrote to their buddies still in the country 
(Howard, 1976). Survivors’ feelings of guilt 
about leaving buddies behind to an unknown fate 
precluded the need to keep in touch (Goodwin, 
1980 ) . It is even rarer to see two or more getting 
together after the war. Contrast this to the con- 
tinual reunions of World War II veterans. 

Another unique factor of Vietnam was its 
guerrilla nature. In World War II, the U.S. was 
confronted by a uniformed, easily recognizable, 
foe. A focus of rage was therefore available to 
the World War II combatant. Vietnam was quite 
the opposite. The enemy was rarely uniformed. 
American troops were often forced to kill women 
and children combatants. There were no real 
geographic lines of demarcation. All land was 
contested and the entire country seemed hostile 
to the Americans. Surprise-firing booby traps 


became the unseen, most feared enemy tactic, 
in which the enemy himself was rarely sighted. 
The war to the combatant became an endless 
line of casualties and rotations with no land won 
or lost and a poorly identifiable foe. Rather than 
an ideologically justifiable experience, the war 
became a private war of survival to each 
American. Rage created by these situations was 
widespread among troops. It showed itself as 
violence and mistrust toward Vietnamese, toward 
authorities, and finally toward the society that 
had sent these troops and then failed to support 
them. 

This also was America's first teenage war 
(Williams, 1979). The average age of the Viet- 
nam combatant was 19.2 years while the average 
of World War II combatant was 26.4 years 
(Wilson, 1979). Developmental models point to 
this period for most adolescents involving 
psychosocial moratorium (Erikson, 1968) dur- 
ing which the individual takes time to build this 
enduring concept of self. This important step — 
identity vs. role confusion — was clearly disrupted 


“The suicide rate is startling. A sober- 
ing fact is that by 1979 more Vietnam 
veterans had died by their oivn hand 
since the tear than actually died in com- 
bat.” 


for the adolescent, combatants via ambiguous 
roles and conflicting values associated with com- 
bat. This led to many subsequent problems. The 
early twenties becomes the time for resolving the 
conflict of “intimacy vs. isolation” (Erikson, 
1968). Without resolution of “identity vs. role 
confusion,” the individual is decidedly handi- 
capped in resolving “intimacy vs. isolation.” 

Vietnam was the first war where tranquilizers 
and phenothiazines were therapeutically ad- 
ministered to combatants (Jones & Johnson, 
1975). This allowed many who might have be- 
come acute combat reaction (shell shock) 
victims of earlier wars to continue to function 
until their DEROS date arrived. 

Self-Medication Routine 

Self-medication via cannibis or opiates was 
routine. The military viewpoint of opiate abuse 
was that the behavior was problematic, and 
opiates users were discharged administratively 
with diagnoses of character disorders (Kormos, 
1978). Interestingly, cannibis users did not 
seem to contribute to a lack of readiness or an 
increase in psychiatric problems. Quite to the 


194 


The West Virginia Medical Journal 


contrary, cannibis seemed to serve a medicinal 
purpose and work as a buffer in submerging and 
delaying symptoms of acute combat reaction 
(Horowitz and Solomon, 1975). 

Finally, when the Vietnam veteran did get 
home, his DEROS fantasy was quickly replaced 
by harsh reality. The civilian population of 
World War II had been exposed to movies about 
the struggle of readjustment by veterans; witness 
“The Man in The Grey Flannel Suit;” “The 
Pride of the Marines,” and “The Best Years of 
Our Lives.” These movies gave the civilian 
population a context in which to consider the 
returning veteran (DeFazio, 1978). On the 
other hand, the civilian population of the Viet- 
nam era had been relentlessly exposed via tele- 
vision’s six o'clock news to the horrors of war. 
They were angry, tired a,nd numb. America was 
not ready psychologically or socially to welcome 
home Vietnam veterans. 

Returning Vietnam veterans found a confused, 
divided country. They had not returned victors 
in any struggle — military, ideologic, psychologic 
or social. Their world had indeed changed, and 
they also had been changed. 

What they experienced in Vietnam and upon 
return will leave a mark that they may never 
erase. To this author, one veteran summed it up 
when he said, “I will go on and try to enjoy 
life again, but I will never be young again . . . 
they stole my youth.” 

Where Were Vietnam Veterans in 1981? 

In a discussion of the purpose of the paper 
with a physican who heads the emergency room 
very near the West Virginia Veterans Admini- 
stration Center in Huntington, he expressed 
doubt that problem-ridden veterans often are 
seen in that facility. His comment was, “We 
don't see many Vietnam veterans with emotional 
problems.’ This remark has allowed the authors 
to understand that he (and certainly others) 
are oversimplifying a huge and complex public 
health problem that goes far beyond “emotional 
problems.” Manifestations of PTSD are diffuse 
and, taken out of context, often are unrecognized 
as a part of the syndrome. 

To assist practitioners in gathering pertinent 
information from their patients, it is necessary 
to give some insight into the type of lives that 
these veterans were leading in 1981. Unemploy- 
ment had become a major problem for these 
veterans. Many felt betrayed in that draft 
resisters and nonveterans in their age group 
were able to continue non-interrupted career and 
educational tracks. Black and socioeconomically 


disadvantaged veterans have less effective peer 
support and, as such, have been especially vulner- 
able to unemployment’s special stresses. The 
temptation is to contend that these individuals, 
regardless of military experience, would occupy 
the same rung on the career ladder. However, 
when background and educational differences 
are controlled statistically, veterans still show 
residual disadvantage in education and occupa- 
tional attainment (Rothbart & Sloan, 1981). 
Vietnam-era veterans as well as Vietnam combat 
veterans exhibit this phenomenon although the 
disadvantages are especially pronounced in com- 
bat veterans. When Vietnam-era and combat 
veterans are compared to their non-veteran peers, 
the striking conclusion has to be that military 
duty in Vietnam bad a negative effect on post- 
military achievements ( Rothbart & Sloan, 
1981). 

Now that most Vietnam veterans are in the 
age group of 30-38 years, it should be noted that 
future attainment of occupational goals probably 
has been irrevocably handicapped (Rothbart & 
Sloan, 1981). 

Concerning the social and psychological prob- 
lems of this group, it has become apparent that 
these men and women are especially troubled by 
problems of alienation, psychiatric symptoms, 
medical problems, drug and alcohol use and 
trouble with the law. Further, it should be under- 
stood that the Veterans Administration as the 
traditional provider of services to veterans has 
been utilized by only a small minority of veterans 
with medical problems. In fact, only about 37 
per cent of Vietnam veterans with residual 
physical problems utilize the VA. These findings 
have been noted by at least two major studies 
including the 1970 National Survey of VA Util- 
ization, and Lauffer. Frey-Wouter, Yager, 1981. 

Depression a Common Problem 

Depression is a common problem of combat 
veterans. Classic symptoms as described in the 
DSM III are the rule: sleep disturbances, 

psychomotor retardation, feelings of worthless- 
ness, inability to concentrate and suicidal 
thoughts plague this group (Williams, 1979). 
Currently, black combat veterans, in fact, report 
stress symptoms at a rate of 70 per cent while 
white veterans report the symptoms at about a 
33-per cent rate (Lauffer, Frey-Wouter, Yager, 
1981 ). The suicide rate is startling. A sobering 
fact is that by 1979 more Vietnam veterans had 
died by their own hand since the war than 
actually died in combat (Williams, 1979). 


i 


September, 1983, Vol. 79, No. 9 


195 




Isolation is a defense adopted by many 
veterans of the Vietnam War. Combat veterans 
have few friends. Many veterans have been able 
to isolate themselves by repeatedly moving from 
one geographic location to another, imposing an 
immense stress on their families in the process. 
It is not rare to find combat veterans who have 
not had social contact with women for years. 
Even those that are married impose rigid isola- 
tion on their wives and children. Ineffective 
resolution of “intimacy vs. isolation” (Erikson, 
1968) due to having to rely only on one’s self 
to survive the combat situation, as well as the 
readjustment to civilian life in a society appear- 
ing apathetic, if not openly hostile, has rein- 
forced this attitude that the veteran can trust only 
himself in life. Veterans have actually taken 
weapons and attempted to live off the land in 
isolated areas of the Rocky Mountains (Williams, 
1979 ). Lynda Vandevanter of Vietnam Veterans 
of America reported that upon the opening of 
the Anchorage, Alaska, Veterans Outreach 
Center, several Vietnam veterans appeared who 
claimed to have lived for years in Alaska’s 
wilderness as hermits. 

Rage is a problem plaguing these men and 
their contacts. Many have been known to strike 
out violently at those around them, including 
wives and children. These frightening episodes 
lead many veterans to question their own sanity 
around this issue. The antennae of the careful 
diagnostician should raise there. Child or spouse- 
abuse problems should provoke a high index of 
suspicion when the father (or mother) is in the 
age group that could include Vietnam veterans. 

Wilson (1979), using his model of Eriksonian 
psychosocial development, estimates that prob- 
lems with this group should increase in incidence 
until 1985 when men and women in the group 
will be moving on to resolution of the next 
stage of psychosocial conflict. 

The legacy of an unresolved conflict in the 
minds of Vietnam veterans promises the 
existence of a huge and lingering public health 
challenge for at least the last two decades of the 
twentieth century. 

Appalachia and Post-Traumatic 
Stress Disorder 

Epidemiologic research indicates that West 
Virginia specifically, and Appalachia in general, 
have a higher prevalence of PTSD than any other 
region of the United States (Giles, 1981). The 
primary reason for this is the high rate at which 
Appalachians were placed in the most lethal 
combat roles. On state-by-state analysis, West 


Virginians suffered the highest casualty rate in 
Vietnam with 85 men losing their life for every 

100,000 males in the 1970 census. This com- 
pares to a national average rate of 55 per 

100.000 males. Based on actual rates, it is pos- 
sible to estimate conservatively that there are 

7.000 West Virginians suffering from PTSD. 1 

On a national level, men from rural states were 
twice as likely to be sent to Vietnam as were 
men from highly urban states (Giles, 1981). 
Casualty rates were generally much higher for 
rural states than urban states. 2 Statistical review 
of Ohio and Kentucky both revealed that Appa- 
lachian counties had casualty rates significantly 
higher than other rural counties and nearly twice 
that of urbanized areas. 

The reasons for this epidemic of PTSD in West 
Virginians are worth speculating about. West 
Virginia has always revered veterans, and was 
generally isolated from the mainstream of anti- 
war sentiment. The military appeared to present 
many options and valuable training for young 
men living in a region of limited vocational 
opportunities. West Virginians are patriotic and 


“ Based on actual rates, it is possible 
to estimate conservatively that there are 
7,000 West Virginians suffering from 
PTSD.” 


have a long heritage of service during war. The 
emotional step from family-oriented to military 
service is relatively easy for Appalachians. It 
represents one of the few accepted ways of 
emancipation from the family. 

Rural men in general, and West Virginians 
specifically, are pre-trained to be good combat 
soldiers. Most have hunted at some time in their 
lives and are comfortable in the woods and with 
weapons. Their family orientation has left them 
with an assumption toward respecting authority. 

1. Studies by Wilson (1979) and Egendorf (1981) as 
well as VA estimates all suggest that there are from 
500,000 to one million veterans suffering from PTSD. 
Research has shown that the best predictor of PTSD is 
combat exposure. Casualty rates are also highly cor- 
related with combat exposure. An assumption is made, 
based on these correlations, that the best estimate of 
prevalence based on geography can be gained by re- 
viewing casualty rates. The authors feel that, conserva- 
tively, there are 10 veterans suffering from PTSD for 
every casualty, and that they reflect the same demography 
as do casualties. This would mean an estimated 570,000 
cases nationwide based on 57,000 casualties. This would 
mean somewhat over 7,000 PTSD cases for the 711 West 
Virginians who were killed in Vietnam. 

2. “Rural” is defined as states with less than 40 per cent 
of the population living in cities. Urban states were those 
with over 80 per cent of the population living in cities. 


196 


The West Virginia Medical Journal 


The military is aware of these factors and 
historically has “funneled” Appalachians into 
combat roles. It is simple personnel psychology. 
Put the right man in the right job. 

In Appalachia, there are many commonly held 
values that must be considered when health care 
services are provided. Weller (1965) has 
pointed out that mountain people have strong 
negative attitudes about people who work in the 
helping professions. He further states that 
Appalachians are afraid of illness and that they 
delay getting care for fear that something may 
be wrong with them. “What is said about sick- 
ness in general is all the truer for mental illness; 
the Mountaineer cannot accept it. ‘Poor nerves’ 
or ‘worn out nerves’ can be blamed for such 
disturbances” (p. 119). 

Emphasis on Personal Relationships 

Appalachians emphasize personal and face-to- 
face relationships, and are confused by the 
impersonal components of health care delivery. 
The Appalachian fears those health care pro- 
viders who use complicated language, rigid time 
schedules, and uncertain explanations. 

In Everything in Its Path, an excellent study 
on the effects of the Buffalo Creek flood, which 
killed 125 West Virginians and destroyed their 
community in February, 1972, Kai Erickson 
(1976) describes many of the values that in- 
fluence Appalachians’ reaction to stress and 
responsiveness to help. 

A primary coping strategy of Appalachians, 
according to Erikson, is a pervasive fatalism. 
Other experts on this region have observed the 
same characteristic. Weller (1965) writes: “The 
sense of fatalism that runs through all of life 
comes into prominent play in medicine ... (It 
provides) a cushion for the mountaineer’s heart 
against the rough times of his life — the death of 
the children, the killing of the husbands in the 
mines or woods” (p. 120). And war. 

This passivity or sense of resignation in the 
face of misfortune is a cultural adaption to the 
physical and economic hardships of the region 
and the lack of control over events. The numb- 
ing caused by exposure to trauma in Vietnam 
often does not generate a great deal of concern 
in Appalachia. It often is labeled as bad nerves, 
and may only become a treatment concern when 
the symptoms become very severe. 

Bad nerves is rapidly becoming a prevalent, 
culturally accepted form of self-diagnosis for 
certain disabling conditions. It is basically a 
medical model or somatic notion that something 
is physically malfunctioning. 


According to Erickson (1976), “the fear of 
disability has become a prominent theme in 
(Appalachian) thinking” (p. 87). He suggests 
that because of their history of physical sturdi- 
ness and survival ability, Appalachians have been 
preoccupied by physical health. Like others who 
share this concern (athletes, dancers, beauty 
contestants), their major apprehension is about 
their health, and they are consumed with con- 
cerns about their aches and pains. 

The Role of the Primary Care Physician 

An in-depth discussion of therapeutic inter- 
vention is beyond the scope of this paper. How- 
ever, the authors hope to follow up with just such 
a discussion. Often the primary care practitioner 
has neither the training nor time to attempt to 
unravel the complex problems of individuals 
in this group. Traditional psychotherapeutic 
methods have not yielded positive results. A 
mass of literature points to the “rap group” con- 
cept of veterans getting together to “work 
through” the Vietnam experience as the most 
promising form of treatment (Egendorf, 1981). 

Across the United States, 133 storefront Vet 
Centers that are staffed with specialists in dealing 
with Vietnam veterans with PTSD have been 
established. In West Virginia, there are offices 
in Charleston, Huntington and Morgantown. 
These centers offer counseling as well as pro- 
viding a channel of referral for Vietnam veterans 
into the community health resources. They pro- 
vide help with discharge review, veterans’ bene- 
fits, legal aid and family counseling. 

Questioning the veteran about possible combat 
exposure is essential in making the diagnosis and 
often helpful in establishing rapport with the 
patient. If the individual is a veteran who feels 
that the combat exposure may be related to his 
problems, the practitioner should consider a Vet 
Center as a referral source. The practitioner can 
appreciate that only the cooperative, willing 
veteran is a good candidate for psychotherapy. 
In-depth probing of specific combat experiences 
may be counter-productive and indeed dangerous 
if not skillfully handled. Medicinal therapy is 
also fraught with hazard if not administered as 
part of a total psychological regimen. Yost 
I 1980 ) warns that use of psychotropic medica- 
tions must be avoided whenever possible. 

Treatment modalities are currently under 
evaluation. This lack of a standardized treat- 
ment plan often makes contact with the Vietnam 
veteran a frustrating experience for the primary 
care provider. In cases where prospects for suc- 
cessful referral are not good, care providers are 


September, 1983, Vol. 79, No. 9 


197 


encouraged to maintain ongoing contact even 
though tenuous due to the high-risk nature of 
this group. 

References 

Archibald HE, Tuddenham RD: Persistent stress 

reactions after combat: A 20-year followup. Arch Gen 
Psychiatry 1965; 12:475-481. 

Bourne PG: Men, Stress and Vietnam, Boston, 

Little Brown, 1970. 

Defazio VJ: Dynamic perspectives on the nature 
and effect of combat stress, in Figley CR (ed): Stress 

Disorders Among Vietnam Veterans: Theory, Research 

and Treatment, New York, Brunner/Mazel, 1978. 

Diagnostic & Statistical Manual III, Washington, 
DC, American Psychiatric Association, 1980. 

Egendorf A: Vietnam Veteran Rap Groups and 

Themes of Post-War Life. J Social Issues: Soldiers In 
and After Vietnam 1975; 31(4) : 1 1 1-124. 

Egendorf A, Kadushin C, Laufer RS, Rothbart G, 
Sloan L: Legacies of Vietnam: Comparative Adjustment 
of Veterans and Their Peers. (Five Vols). Vol I— Sum- 
mary. Vol II— Education and work careers: Men in the 
Vietnam generation, Rothbart G, Sloan L. Vol Ill- 
Post- war trauma: Social & psychological problems of 

Vietnam veterans in the aftermath of the war, Laufer 
RS. Vol IV— Long-term stress reactions: Some causes, 

consequences and naturally occurring support systems, 
Kadushin C. Vol V— Dealing with the war: A view 

based on the individual lives of Vietnam veterans, Egen- 
dorf A, New York City, Center for Policy Research, Inc, 
March, 1981. 

Erikson E: Youth, Identify and Crisis, New York, 
WW Norton, 1968. 

Erikson K: Everything in Its Path, New York, 

Brunner/Mazel, 1978. 

Figley CR: In Figley CR (ed): Stress Disorders 
Among Vietnam Veterans: Theory, Research and Treat- 
ment, New York, Brunner/Mazel, 1978. 

Futterman S, Pumpian-Mindlin E: Traumatic war 
neuroses five years later. Am J Psychiatry 1951, 108(b): 
401-408. 

Giles SL: Appalachia’s forgotten warriors: Out- 
reach service for Vietnam veterans, in: New Directions 
for Mental Health Services, Chicago, September, 1981. 

Glass AJ : Psychotherapy in the combat zone. Am 
J Psychiatry 1954, 110:725-731. 

Glass AJ: Introduction, in Bourne PG (ed): The 
Psychology and Physiology of Stress, New York, Aca- 
demic Press, 1969, XIV-XXX. 


Goodwin J : Etiology of combat-related post- 

traumatic stress disorders, in: Post-Traumatic Stress Dis- 
order of the Vietnam Veteran, Cincinnati, Ohio, DAV 
Press, 1980, Ch I. 

Grinker RR, Spiegel JP: Men Under Stress, 

Philadelphia, Blakiston, 1945. 

Horowitz MJ, Solomon GF : A prediction of 

delayed stress response syndromes in Vietnam veterans, 
in Mantell DM, Pilisuk M(eds): J Social Issues: Soldiers 
In and After Vietnam 1975; 31(4):67-80. 

Howard S: The Vietnam warrior: His experiences 
and implications for psychotherapy. Am ] Psychother 
1976; 30(1): 121-135. 

Jones FD, Johnson AW: Medical psychiatric 

treatment policy and practice in Vietnam, in Mantell 
DM, Pilisuk M (eds): Social Issues: Soldiers In and 

After Vietnam 1975; 31(4):49-65. 

Kormos HR: The nature of combat stress, in 

Figley CR (ed): Stress Disorder Among Vietnam Vet- 
erans: Theory, Research and Treatment, New York, 
Brunner/Mazel, 1978. 

Mental health problems of Vietnam era vererans, 
President’s Commission of Mental Health Report of 
Special Working Group, Washington, DC, Feb 15, 1978. 

Shatan CF: Stress disorders among Vietnam 

veterans: Emotional content of combat continues, in 

Figley CR (ed): Stress Disorders Among Vietnam Vet- 
erans: Theory, Research and Treatment, New York, 
Brunner/Mazel, 1978. 

Tiffany WJ, Allerton WS: Army psychiatry in 

the mid-60s. Am J Psychiatry 1967; 123:810-821. 

Williams T: Vietnam veterans— unpublished, Uni- 
versity of Denver, School of Professional Psychology, 
Denver, Colorado, April, 1979, excerpts in: Post-Trau- 
matic Stress in Vietnam Veterans, Cincinnati, Ohio, DAV 
Press, 1980. 

Wilson JP: Part I— Identity, ideology and crisis: 
Vietnam veterans in transition. Part II— Psychosocial 
attributes of the veteran beyond identity: Patterns of 

adjustment and future implications, in: Forgotten War- 
rior Project, Cleveland State University, 1978. Reprinted 
by DAV, Cincinnati, Ohio, 1979. 

Wilson JP: Conflict, stress and growth: Effects of 
Vietnam War on psychosocial development among Viet- 
nam veterans, in Figley CR, Leventman S (eds): 
Strangers At Home: Vietnam Veterans Since the War, 
Praeger Press, 1980. 

Yost J : Psychopharmacologic treatment of the 

delayed stress syndrome in Vietnam veterans, in: Post- 
Traumatic Stress Disorders of the Vietnam Veterans, 
Cincinnati, Ohio, DAV Press, 1980, Ch VI. 


198 


The West Virginia Medical Journal 


Practical Tips On Adverse Drug Effects 
In Glaucoma Therapy* 


LARRY T. SCHWAB, M. D. 

Project Ophthalmologist, Malawi Blindness Prevention 
and Training Project, Blantyre, Malawi, Africa; and 
Clinical Associate Professor of Ophthalmology, West 
Virginia University School of Medicine, Morgantown 


There are four major groups of drugs utilized 
by the ophthalmologist for managing glaucoma 
outpatients. They are parasympathomimetics, 
sympathomimetics, carbonic anhydrase inhibi- 
tors, and beta-adrenergic receptor blocking 
agents. Although the route of administration in 
three of these classes of drugs I all groups except 
carbonic anhydrase inhibitors ) is topical, there 
can be systemic absorption through the lacrimal 
drainage system to produce significant systemic 
side effects. The fourth group, carbonic an- 
hydrase inhibitors, also may have potentially 
serious side effects. 

Seven clinical situations are presented for the 
practitioner managing patients who are taking 
antiglaucoma medications. The primary care 
physician is urged to maintain a high index of 
suspicion and be alert to these side effects in 
glaucoma patients taking these agents. The 
physician should consult closely with the 
patient's ophthalmologist in managing systemic 
complications from glaucoma medications. 

Seven Clinical Situations 

1. The patient’s presenting complaint is 
frontal headache. The physicial examination 
reveals miotic and fixed pupils. The patient is 
likely using a topical parasympathomimetic 
preparation for treatment of open-angle glau- 
coma. Parasympathomimetics may cause blurred 
vision and pain in the supraorbital and frontal 
areas. The miotic medication may be responsible 
for the patient’s complaint. 

2. The patient’s complaint is cramping, 
nausea, and diarrhea. Physical examination 
reveals miotic pupils. The miosis may he due 
to topical anticholinesterase therapy for open- 
angle glaucoma which also may be producing 
these cholinergic systemic side effects. 

3. A patient who has been on chronic anti- 
cholinesterase therapy for glaucoma may ex- 

“This paper was written while Doctor Schwab was 
Assistant Professor, Department of Ophthalmology, West 
Virginia University School of Medicine, Morgantown. 


perience prolonged apnea in the postanesthetic 
period if succinylcholine is utilized in induction. 
The anesthesiologist should be alerted. 

4. A patient with open-angle glaucoma who 
is being managed for hypertension should be 
questioned carefully about antiglaucoma medi- 
cations. Chronic use of topical epinephrine may 
aggravate his hypertension. Dipivefrin (a pro- 
drug) should be substituted in this situation, 
virtually eliminating the adverse effect of 
epinephrine on blood pressure. 

5. Carbonic anhydrase inhibitors may cause 
chronic gastrointestinal upset, parasthesias, and 
weight loss. Occasionally, a glaucoma patient 
who is being maintained on one of these medi- 
cations I Diamox, e.g. ) is hospitalized and in- 
vestigated for neurologic disease or malignancy. 
The patient with glaucoma and these symptoms 
should be questioned carefully about the use of 
carbonic anhydrase inhibitors. An unnecessary 
and costly workup may be avoided if it is known 
that one of these drugs is responsible for the 
patient’s complaints. 

6. Carbonic anhydrase inhibitors may pre- 
cipitate renal calculi. They should be discon- 
tinued in patients with a positive family or 
personal history for kidney stones. Close co- 
operation with the patient’s ophthalmologist is 
encouraged for optimum patient care. 

7. A glaucoma patient who presents for evalu- 
ation of dyspnea should be questioned about the 
use of topical timolol maleate. This beta-receptor 
blocking agent may precipitate or aggravate 
dyspnea in chronic obstructive pulmonary 
disease, congestive heart failure, and bronchial 
asthma. 

Background Data 

Glaucoma is the number one cause of legal 
blindness in the United States. It was responsi- 
ble for 12.5 per cent of all legal blindness in 
1978. 1 While it is not a major blinding disease 
in the under-45 age group, it becomes a major 
cause of blindness after 45. The National 
Society to Prevent Blindness estimated that 
62.100 individuals were blind from glaucoma in 
1978. The prevalence rate of glaucoma rises 
sharply in the seventh decade. The prevalence 
rate is 27.7/100,000 population in the 45 to 64 
age group for both sexes. The rate rises sharply 


September, 1983, Vol. 79, No. 9 


199 


to 115.5/100,000 population in the 65 to 74 age 
group, and 290.0/100,000 in the 75 to 84 age 

group. 

It is obvious that glaucoma is a common 
ophthalmic problem in the geriatric population. 
Many geriatric patients managed for chronic 
cardiovascular illness also may be treated for 
open-angle glaucoma. Many medications used 
by the ophthalmologist in treating glaucoma have 
potentially serious systemic side effects, particu- 
larly in the geriatric patient with cardiovascular 
disease including hypertension. 

Classes of Glaucoma Agents and 
Pharmacologic Actions 

Pharmacologic agents for the management of 
glaucoma may be divided into five groups: 
parasympathomimetics, sympathomimetics, car- 
bonic anhydrase inhibitors, beta-adrenergic 
blocking agents, and osmotic agents. Let us 
examine each group separately, with emphasis 
on systemic side effects and adverse drug 
reactions. We will not consider the local ocular 
side effects. 

Parasympathomimetics : 

Three types of parasympathomimetic agents 
are used widely in treating glaucoma patients: 
cholinomimetic alkaloids (pilocarpine); choli- 
nesters (carbachol); and cholinesterase inhibitors 
(echothiophate iodide, isoflurophate, deme- 
carium, and physostigmine). 

Pilocarpine, a cholinomimetic, is a safe, in- 
expensive, and widely-used topical miotic. The 
cholinesterase inhibitors are potentially toxic. 
Potential side effects with these agents include 
possible “cholinergic crisis.” This should be 
suspected if the patient exhibits lacrimation, 
salivation, nausea, vomiting, diarrhea, and 
diaphoresis. A history of recent administration 
of a topical anticholinesterase should alert the 
practitioner to this diagnosis. 

There also is a risk of anesthetic catastrophe 
in patients who have been treated chronically 
with anticholinesterases. Because of the presence 
of pseudocholinesterases in these patients, 
succinylcholine may not be degraded in the 
postanesthetic period, and prolonged apnea may 
result. The use of succinylcholine in general 
anesthesia in patients on anticholinesterases 
should be undertaken with caution. If the patient 
is being treated with an anticholinesterase agent 
and is to undergo general anesthesia, alert the 
anesthesiologist. 2 


Sympathomimetics : 

Sympathomimetics include epinephrine and 
dipivefrin hydrochloride. Epinephrine hydro- 
chloride and epinephrine bitrate one- and two- 
per cent solutions, administered topically every 
eight hours, reduced the formation of aqueous by 
the ciliary body epithelium. They have little di- 
lating effect on the pupil (mydriasis). Topical 
epinephrine solution may be absorbed systemi- 
cally through the lacrimal drainage system and 
aggravate or cause hypertension. 

Topical epinephrine compounds should not be 
used in geriatric patients with hypertension and 
cardiac arrhythmias. Elderly patients who are 
being treated with digitalis preparations and 
diuretics may be potassium depleted. A serious 
and possibly life-threatening arrhythmia may be 
precipitated by the administration of small 
amounts of topical epinephrine in potassium- 
depleted patients. Cerebral vascular accident 
and myocardial infarction are potential risks in 
patients with hypertension who are treated with 
topical epinephrine. 

Dipivefrin hydrochloride may be used to ad- 
vantage in glaucoma patients who respond to 
sympathometics. This agent is a prodrug and is 
not converted to its active form until it is 
absorbed intraocularly. 3 The systemic side 
effects of topical epinephrine may thus be 
avoided. 

Carbonic Anhydrase Inhibitors : 

Carbonic anhydrase inhibitors include aceta- 
zolamide (Diamox®), methazolamide, dichlor- 
pehnamide, and ethoxzolamide. Of this group, 
acetazolamide (Diamox) is the most widely-used 
agent. These preparations are available in tablet 
and capsule form, and Diamox is available as a 
sequel preparation. 

Diamox was used as a diuretic in hypertension 
prior to the development of more specific and 
effective diuretics. It reduces the production of 
aqueous fluid by the ciliary body epithelium by 
as much as 50 per cent. 

Side effects and adverse reactions from car- 
bonic anhydrase inhibitors are numerous. They 
include: paresthesias in extremities and digits; 
gastrointestinal disturbances including nausea, 
dyspepsia, cramps, and diarrhea; fatigue, weight 
loss, and malaise; decreased libido, impotence, 
and depression; exfoliative dermatitis; and 
Stevens- Johnson syndrome. Carbonic anhydrase 
inhibitors alkalinize the urine and cause meta- 
bolic acidosis. 


200 


The West Virginia Medical Journal 


The pharmacotherapeutics of glaucoma have 
improved dramatically in recent years with the 
development of new and effective antiglaucoma 
agents. Fewer patients with open-angle glaucoma 
are maintained long-term on carbonic an- 
hydrase inhibitors. These drugs are now used 
mainly in acute (angle-closure) glaucoma and 
prior to intraocular surgery. 

Beta-Adrenergic Receptor Blocking Agents: 

The development of an effective anti-ocular 
hypertensive beta-adrenergic receptor blocking 
agent was an exciting new breakthrough in 
ocular pharmacology. Timolol maleate (Timo- 
ptic) is available in concentrations of 0.25-per 
cent and 0.5-per cent solutions; it is administered 
topically every 12 hours. 4 It reduces intraocular 
pressure by decreasing the rate of formation of 
aqueous by the ciliary body epithelium 5 ; it also 
may increase the outflow of aqueous from the 
anterior chamber. It has no effect on accom- 
modation or pupillary size. 

Timolol maleate may produce general side 
effects of bradycardia and lowered blood pres- 
sure when it is absorbed systemically through 
the lacrimal drainage system. Bronchospasm also 
may be a side effect. This agent is contraindi- 
cated in patients with congestive heart failure, 
bronchial asthma, and chronic obstructive pul- 
monary disease. 

Drugs Which Don't Affect Glaucoma 

The Physicians’ Desk Reference and package 
inserts for numerous medications warn of the risk 
of glaucoma with systemic administration. These 
drugs include the antispasmotics, the antihista- 
mines, and the antiparkinsonian agents. Rarely, 
if ever, do these drugs produce ocular hyper- 
tension or glaucoma. 

Several agents potentially may have minimal 
pupillary-dilating effect. A dilated pupil may 


precipitate an attack in a patient with a history 
of angle-closure glaucoma. This event would be 
more likely if the agent is administered topically 
to the eye. When used systemically, however, it 
has practically no effect on the, pupil. 

Atropine sulfate administered systemically 
preoperatively almost never precipitates an at- 
tack of angle-closure glaucoma. 

It also should be noted that the drugs in these 
three groups have no effect on open-angle 
glaucoma. 

Conclusions 

The drugs used by ophthalmologists in manag- 
ing glaucoma may have potentially serious 
systemic side effects. Glaucoma patients may 
not associate their systemic complaints with their 
glaucoma treatment regimen; consequently, 
these complaints may then come to the attention 
of the general physician. 

There are four major drug groups widely 
utilized for glaucoma management. Side effects 
and complications among these medications are 
varied, and some are potentially life-threatening. 

Antispasmotics, antihistamines, and anti- 
parkinsonian drugs may be used when indicated 
systemically without the risk of precipitating 
angle-closure glaucoma. 

References 

1. Vision Problems in the 17. S. National Society to Pre- 
vent Blindness, 1980, New York, p 11. 

2. Rawlings EF, Zimmerman TJ : Medical manage- 

ment of open-angle glaucoma. Ocul Ther Surg Nov-Dec, 
1981; p 91. 

3. Kaback MB, Podos SM, Harbin JS, et al.i The 
effects of dipivalyl epinephrine on the eye. Am ] 
Ophthalmol 1976; 81 . -768-772. 

4. Zimmerman TJ, Kaufman HE: Timolol, dose- 

response and duration of action. Arch Ophthalmol 1977; 
95:605-607. 

5. Coakes RL, Brubaker RF: The mechanism of 

timolol in lowering intraocular pressure in the normal eye. 
Arch Ophthalmol 1978; 96:2045-2048, 1978. 


September, 1983, Vol. 79, No. 9 


201 


ad meAAage from . . . 



*jke PzeAident 


STRATEGY FOR CHANGE 


Tt is with anticipation, excitement and appre- 

hension that I begin to serve my year as your 
President. I do appreciate this opportunity and 
will need the cooperation and support of the 
membership if we are to be successful. 

During the next 12 months, I will be using 
this page to address specific issues that will be of 
major concern to the Association and to the 
practice of Medicine. One of the paramount con- 
cerns will be to develop a framework of analysis 
so that a strategy can be formulated to deal with 
the changing structure of the health care system. 

It is obvious that the emerging structure will 
he far different from the traditional private 
practice model. It will be very difficult for solo 
physicians to compete in the future marketplace: 
in fact, large groups may be necessary to com- 
pete effectively with health maintenance organ- 
izations, urgent care centers, and proprietary 
clinics managed by the large hospital corpora- 
tions. 

The concept of DRGs must be understood and 
incorporated into the planning process. Com- 
petitive bidding (contract negotiations) will be 
required as government agencies and corpora- 
tions begin to apply pressure for medical services 


to be responsive to the law of supply and demand. 
The emergence of non-physician providers will 
continue to escalate. Competition between 
hospitals and their medical staff will be intense 
and will be amplified by the physician surplus of 
the next decade. The list goes on and on. . . . 

Physicians must not be passive in adapting to 
these changes. They must be aggressive and 
develop long-range plans which will be formu- 
lated after careful consideration of the relevant 
factors. These plans must be developed now. 
Otherwise, physicians will be constantly reacting 
to each isolated change in the medical structure. 

I hope that your State Association will be able 
to provide assistance and suggestions to the 
membership in developing future strategies. Per- 
haps my most important role over the next year 
will be to serve as a catalyst as these various 
changes are discussed, and together we plan a 
strategy for change. 

CM 

Carl R. Adkins, M. D„ President 
West Virginia State Medical Association 


202 


The West Virginia Medical Journal 


the Vest Virginia fledical Journal 

Editorials 

The Publication Committee is not responsible for the authenticity of opinion or statements made by authors or 
in communications submitted to this Journal for publication. The author shall be held entirely responsible. 
Editorials printed in The Journal do not necessarily reflect the official position of the West Virginia State 
Medical Association. 


Starting with a hospital’s first cost-reporting 
period after October 1, a diagnosis-related 
groups (DRG) reimbursement system goes into 
effect for inpatient Medicare reimbursement. 
Congressional action as of last March provides 
for phasing in DRG payments over three years. 

Before enactment of the legislation, the Ameri- 
can Medical Association and others called for 
controlled experimentation with this system, as 
well as others, before na- 
DRG CONCERNS tional implementation. But 
the DRG arrangement was 
enacted despite any reliable data about how it 
really will work over a long period of time. 

Because the untested nature of the mechanism 
raises concerns about any number of things, in- 
cluding a most important potential effect on 
accessibility and quality of care, a need for 
further study of the DRG system remains as 
strong as ever. 

The question is, will such a study be con- 
ducted, and by whom and how? What about a 
concern that hospitals, as a group, will have no 
incentive to improve efficiency under a DRG 
system because such improvements might lead 
to a reassessment and lowering of the overall 
reimbursement level? 

Will hospital management place pressure on 
a medical staff to tailor length of stay and 
utilization of hospital resources to a patient’s 
DRG? Will the system create incentives to in- 
crease reimbursement by upgrading the severity 
of admitting diagnoses in a practice which has 
been labeled “DRG creep?’’ 

These are very real and critical questions with 
respect to DRGs, which provide a system that 
sorts patients into diagnostic categories that at 
least theoretically are medically similar and 
have an anticipated equivalent length of stay. 

Under such a reimbursement system, insurers 
and other purchasers of hospital care pay a 
single amount for the treatment of an illness, 
regardless of variations in specific services pro- 
vided to patients with the same diagnosis. Pay- 


ment is linked directly to the average cost of 
treating a particular condition. 

Against this general background, it’s logical 
to see why the questions above can, and should, 
be raised. The federal legislation also contains, 
it must be stressed, a provision that could pave 
the way for extending the DRG concept to 
physician charges for inpatient hospital services 
provided Medicare beneficiaries. 

Another major question is whether DRGs can 
demonstrate adequately an effectiveness as a way 
of paying hospitals, let alone physicians. Further, 
will the system shift Medicare costs to the private 
sector, and will initial and continuing administra- 
tive costs for hospitals exceed the anticipated 
cost savings, since only 25 per cent of the 
average hospital caseload is made up of Medicare 
beneficiaries? 

These are very real concerns, and the position 
of the AMA, among others, is exactly right. A 
need for further study of this whole concept, 
despite Congress’ action in setting up DRGs for 
Medicare, is undiminished. 


Contrary to an all-too-popular view, West Vir- 
ginia is not always last — at least, not in every- 
thing. With strong State Medical Association 
support, the Legislature enacted in 1981 a statute 
to require the use of approved restraint systems 
for children riding in motor vehicles. 

The state followed close on the heels of 
Tennessee, where such protective legislation for 
infants first became law. As of 
CHILD SAFETY April of this year, 31 states and 
the District of Columbia had 
child passenger safety laws; five legislative acts 
were on governors’ desks for action, and virtually 
all other states had bills in the legislative process 
either to establish such restraints or tighten 
existing law r s. 

According to the National Safety Council, the 
highest infant death rate resulting from motor 
vehicle accidents occurs in the first year of life, 


September, 1983, Vol. 79, No. 9 


203 



particularly the first six months. It counted at 
least 720 deaths and 2,900 injuries in 1981 
among children under five. 

The West Virginia statute requiring an ap- 
proved restraint system stipulates a car bed or 
a car seat for a child up to age three, with a 
seat belt deemed sufficient for one between the 
age of three and five. 

Others, such as safety councils and the Ameri- 
can Academy of Pediatrics, likewise have played 
key roles in the child restraint program. Strong 
support has come from the American Medical 
Association’s House of Delegates. 

Much remains to be done to educate parents, 
in particular, in the area of child passenger 
safety. Automobile clubs have taken a lead role 
in this effort, including making approved car 
seats and the like available to vehicle owners. 
In this general concern, West Virginia has been 
a leader. 


A number of West Virginia physicians know 
William Guillette, M. D. The former general 
practitioner who now is vice president of a 
national consultant-actuary firm was for 18 years 
with Aetna Life and Casualty, where he was 
medical director of the casualty and group- 
health claim departments. 

Doctor Guillette recently composed quite a 
lengthy piece on keys to containing health 

care costs. It 

SUCCESSFUL COST CONTROL was enlighten- 

PROVIDER-MOTIVATED ing, bluntly but 

thoroughly pre- 
sented, and, yes, it probably raised the hackles 
of some of his colleagues. Much of the material 
probably had been presented in similar detail 
before, but it still provoked some thought. 

For example, Doctor Guillette noted that of 
all the payment-control programs he mentioned 
in his article, the ones that were the most suc- 
cessful in controlling health care costs were 
motivated primarily by the provider — not by the 
consumer or the employer. He cited the two 
most successful as a well-run Health Maintenance 
Organization (HMO) and ambulatory surgery. 

How have quality HMOs led the pack in pro- 
viding good health care and containing costs? 
“By controlling hospitalizations; more specifi- 
cally, by avoiding unnecessary hospitalizations,” 
Doctor Guillette said. 

“Once an HMO patient is hospitalized, his 
or her length of stay generally is about the same 
as for non-HMO patients,” he added. “It is by 
avoiding hospitalization — by encouraging ex- 


tensive ambulatory serivces — that the big 
savings are achieved.” 

“The other major payment-control program 
that has the capacity to save significant dollars 
is ambulatory surgery, a concept that was 
pioneered by two anesthesiologists in Phoenix,” 
Doctor Guillette continued. He then explained: 

“Hospitals balked at offering this alternative, 
until the proliferation of ambulatory surgical 
centers — started by physicians — convinced them 
that they had best get into the act. 

“The newest example of the changing market- 
place is the development of the preferred-pro- 
vider organizations put together by physicians 
and hospitals. They offer discounts on their 
services, in return for prompt payment and 
access to more patients. 

“Why have these programs been so much more 
successful than second opinions, pre-admission 
authorizations, or PSROs? Very simply, because 
most of the other programs were proposed by 
government agencies or by insurance companies, 
and jammed down the physicians’ throats. And, 
as stated earlier, none of these programs will 
work without the full cooperation of the medical 
community. 

“Cost-containment programs must be struc- 
tured to motivate both the doctor and the patient 
to want to do things economically — without 
sacrificing quality. Some would say that these 
two goals are incompatible; I say not. As evi- 
dence, I refer you to the many fine medical 
institutions which are currently offering high- 
quality care at competitive prices.” 


Robert P. Johnson, M. D., President of the 
Illinois State Medical Society, thinks the “posi- 
tive futurist” doctor must have a keen recogni- 
tion of marketplace in- 
'POSITIVE FUTURIST' fluences; and accommodate 
overall government spend- 
ing reductions as well as less first-dollar health 
insurance coverage. 

He or she will anticipate greater business 
efforts to cut health care costs, and reconfigura- 
tion of the overall medical care delivery system. 
Better understanding of the changing environ- 
ment, and contingency plans for delivering medi- 
cal care, will be essential. 

The “positive futurist” M. D. will learn to 
forecast events; prepare personal blueprints; ad- 
just to a more competitive marketplace — and 
stay flexible. “These skills will enable the doctor 
to meet the challenges of Medicine in the decades 
to come,” Doctor Johnson predicts. 


204 


The West Virginia Medical Journal 


GENERAL NEWS 


Parkinsonism, Disability Topics 
In 17th Mid-Winter Lineup 

Parkinsonism and organic brain syndrome will 
be among subjects discussed during the 17th 
Mid-Winter Clinical Conference next January 
27-29 in Charleston. 

Opening Friday afternoon, January 27, and 
ending at noon on Sunday, the annual continuing 

education event again 
is being sponsored by 
the State Medical As- 
sociation and the Mar- 
shall University and 
West Virginia Univer- 
sity Schools of Medi- 
cine. The site, for the 
second year, will be the 
Marriott Hotel. 

Among other CME 
offerings being planned 
for the three-day affair 
by the Program Com- 
mittee will be a special 
Saturday afternoon session on “Into and Out of 
the Disability Trap,” an in-depth panel discus- 
sion, emphasizing audience participation, on the 
physician and procedures and pitfalls in dis- 
ability determination. 

Preliminary plans for the disability program 
call for a physician moderator, with a panel in- 
cluding an employer’s attorney, an attorney 
familiar with claimants’ cases, disability officials 
from state and federal agencies, and an in- 
dependent rehabilitation representative. 

The Parkinsonism-organic brain syndrome 
paper will be presented by Dr. Albert F. Heck, 
Charleston neurologist, during the Saturday 
morning session. Doctor Heck is Clinical Pro- 
fessor of Neurology, WVU Medical Center, 
Charleston Division, and staff neurologist at 
Charleston Area Medical Center. 

Other Topics 

Other program topics planned by the Program 
Committee include AIDS; handling of children 
from broken homes; flexible sigmoidoscopy; 


seizures; geriatric pharmacology; new treatment 
in disc diseases; arthritis; and streptokinase in 
the treatment of heart disease. 

Plans for the annual Friday evening physi- 
cians’ session have not yet been announced. 

Help for rape and incest victims will be ex- 
plored during the Friday evening public session. 

Prior to coming to Charleston in 1982, Doctor 
Heck was Professor and Chairman, Department 
of Neurology, University of Tennessee, and 
Director, Neurosciences Program, University of 
Tennessee Center for Health Sciences, in 
Memphis. He also was Director of the Neurology 
Residency Training Program at the University. 

A native of Baltimore, Doctor Heck was 
graduated from Johns Hopkins University, and 
received his M. D. degree in 1958 from the Uni- 
versity of Maryland. He interned at Mercy 
Hospital in Baltimore, and took his residency in 
neurology at the National Institutes of Health 
and the University of Maryland. He was certified 
in 1966. 

Doctor Heck is a member of Alpha Omega 
Alpha Honor Medical Society, and a Fellow of 
the American Academy of Neurology, the Stroke 
Council, American Heart Association, and the 
International College of Angiology. 

Teaching, Other Posts 

He held several teaching positions, rising to 
the rank of Professor of Neurology, at the Uni- 
versity of Maryland before going to the Uni- 
versity of Tennessee in 1977. Currently, he is 
Senior Editor and a member of the Publications 
Committee for Vascular Medicine, and Vice 
President of the American College of Angiology. 

Doctor Heck is the author of three book 
chapters, and the author or co-author of 54 
abstracts and articles. 

Members of the Program Committee are Drs. 
Joseph T. Skaggs, Chairman, William 0. Mc- 
Millan, Jr., and C. Carl Tully, all of Charleston; 
Maurice A. Mufson, Huntington; Robert L. 
Smith, Morgantown, and Richard G. Starr, 
Beckley. 

The Committee receives continuing assistance 
from WVU Charleston Division staff members J. 



Albert F. Heck, M. D. 


September, 1983, Vol. 79, No. 9 


205 


Zeb Wright, Ph.D., Coordinator of Continuing 
Education, Department of Community Medicine; 
and Sharon A. Hall, Conference Coordinator. 

More information concerning other speakers 
and subjects will be provided by the Program 
Committee in upcoming issues of The Journal. 


Marshall Entering Class 
Has 48 Students 

Fourteen West Virginia counties are repre- 
sented in the Marshall University School of 
Medicine entering class, according to Cynthia 
Warren, Assistant Director of Admissions. 

The 48-member class also will include two 
residents from Ohio and one each from Kentucky 
and Virginia. 

“One of the most interesting things about this 
year’s entering class is its age — the average 
age is 26.1 years, quite a jump over last year’s 
average age of 24.9 years,” Ms. Warren said. 
“We have new students as young as 21 and as 
old as 41.” 

She reported that the school’s Admissions 
Committee interviewed 224 of 490 applicants. 
Of the 48 chosen, 35 are male and 13 female. 
Thirty-five students are starting with bachelor’s 
degrees, 10 with master’s degrees and three with 
doctoral degrees (two of them pending). 

Six West Virginia colleges and universities 
are represented in the class: Marshall. West Vir- 
ginia University, West Virginia State College, 
Fairmont State College, the University of 
Charleston, and West Virginia Wesleyan College. 

The students and their hometowns are: 

Cabell : Pamela G. Bailey, Barbara Bolton, 

D. Diane Bowen, Nancy L. Graham, Darlene Y. 
Gruetter, Christopher E. Hayner, James T. Hol- 
brook, Allen B. Joseph, David C. Kowalski, 
Robert E. Mehl, Jr., Manuel E. Molina, Jose A. 
Ottaviano, Mark F. Sheridan, Bartlett A. Stone, 
Glen E. Vanderzalm, and William M. Skeens, all 
of Huntington, and Shawn W. Coffman of Salt 
Rock; 

Kanawha: Joseph P. Assaley, C. Steven 

Batiste, C. Stephen Edwards, James C. McCabe, 
Yaacov R. Pushkin, Suzanne I. Starkey, Gary 
R. Youmans and Jeanne M. Zekan, all of Charles- 
ton; Charles Bukovinsky of Dunbar; and Sandra 
Y. Elliott and Paul T. Kuryla, both of St. Albans; 

Harrison: Randall F. Hawkins of Bridgeport; 
Jefferson: Thomas S. Wilson of Charles Town; 
Marion: Kevin M. Clarke and Danny M. Phillips, 
both of Fairmont; Mason: Martha N. Boonsue 
of Point Pleasant; Mercer: Ignacio Cardenas of 


Princeton; Monongalia: Imelda D. Stevenson of 
Morgantown; Nicholas: Melody A. Eiseman of 
Nettie; Raleigh: James A. Barnes, Jr., of 

Beckley; 

Upshur: Darin K. Bowers of Buckhannon; 

Wayne: J. Michael Cassidy of Kenova, James 
F. Spears II of Fort Gay and Sheryl L. Stephens 
of Ceredo; Wood: Todd A. Broome and Yale D. 
Conley, both of Vienna; Wyoming: Charles A. 
Garretson of Mullens; Belmont (Ohio): Mark 
E. Coggins of Shadyside, and Lawrence (Ohio): 
Linda J. Hathaway of South Point; Floyd 
(Kentucky): Rondal E. Goble of Prestonsburg, 
and Tazewell (Virginia) : Donald W. Asbury of 
Bluefield. 


Hal Wanger Family Practice 
Program November 3-5 

A variety of some 15 medical subjects will be 
discussed during the ninth annual Hal Wanger 
Family Conference November 3-5 in Morgan- 
town. 

The meeting site will be the West Virginia 
University Medical Center Auditorium, with 
WVU faculty members presenting the scientific 
program. 

Sponsors are the WVU Department of Family 
Practice, WVU Office of Continuing Medical 
Education, and the West Virginia Chapter of the 
American Academy of Family Physicians. 

Discussion topics will include: 

Doppler techniques in diagnosing congenital 
heart disease; diagnostic virology and immune 
incompetence; lupus; urologic problems in chil- 
dren; coronary bypass surgery; stress inconti- 
nence; pacemakers; hearing loss in children; 

Adult-onset muscle weakness; avoiding prac- 
tice faux pas; exercise in osteoporosis; diagnos- 
ing seizure disorders; diagnostic radiology; 
plasmophoresis in rheumatoid arthritis; and head 
and neck injuries in sports. 

Also scheduled are lectures and demonstra- 
tions on the use of personal computer systems 
for maintenance of data and records in a 
physician’s practice; and a hands-on ENT 
“practicum” to acquaint primary care physicians 
in the use of direct and indirect laryngoscopy, 
nasal packing for epistaxis, tympanometry, and 
audiometry. 

The conference meets the criteria for 17 hours 
of credit in Category 1 of the Physician’s Recog- 
nition Award of the American Medical Associa- 
tion; is acceptable for 17 hours by the American 
Academy of Family Physicians; and is approved 
for 1.7 WVU continuing education units. 


206 


The West Virginia Medical Journal 


Continuing Education 
Activities 

Here are the continuing medical education 
activities listed primarily by the West Virginia 
University School of Medicine for part of 
1983, as compiled by Dr. Robert L. Smith, 
Assistant Dean for Continuing Education, and 
J. Zeb Wright, Ph. D., Coordinator, Con- 
tinuing Education, Department of Community 
Medicine, Charleston Division. The schedule is 
presented as a convenience for physicians in plan- 
ning their continuing education program. (Other 
national, state and district medical meetings are 
listed in the Medical Meetings Department of 
The Journal.) 

The program is tentative and subject to 
change. It should be noted that weekly confer- 
ences also are held on the Morgantown, Charles- 
ton and Wheeling campuses. Further information 
about these may be obtained from: Division of 
Continuing Education, WVU Medical Center, 
3110 MacCorkle Avenue, S. E., Charleston 
25304; Office of Continuing Medical Education, 
WVU Medical Center, Morgantown 26506; or 
Office of Continuing Medical Education, Wheel- 
ing Division, WVU School of Medicine, Ohio 
Valley Medical Center, 2000 Eoff Street, Wheel- 
ing 26003. 

Sept. 3, Morgantown, Treatment Options in 
Arthritis* 

Sept. 9-10, Morgantown, Ob/Gyn Teaching 
Days* 

Sept. 14, Charleston, Advances in Hypertension 

Sept. 16-17, Charleston, Advanced Trauma Life 
Support Course 

Oct. 1, Morgantown, Issues in Geriatric Medi- 
cine* 

Oct. 5, Charleston, Gastroenterology Update 
Oct. 14, Morgantown, Ophthalmology Conference 

Oct. 15, Morgantown, Common Problems in 
Nephrology* 

Oct. 28-29, Morgantown, Fourth Diagnostic 
Ultrasound Conference 

Nov. 3-5, Morgantown, Ninth Annual Hal 
Wanger Family Practice Conference* 

Nov. 11-12, Morgantown, Fourth Sports Medi- 
cine Symposium* 

Nov. 14, Charleston, Medicine and Ministry in 
Cooperative Patient Care 

0 Held in conjunction with WVU home football game. 


Regularly Scheduled Continuing 
Education Outreach Programs from 
WVU Medical Center/ 
Charleston Division 

Buckhannon, St. Joseph’s Hospital, first-floor 
cafeteria, 3rd Thursday, 7-9 P. M. — Sept. 
15, “Update on Oncological Chemotherapy,” 
Steven Jubelirer, M. D. 

Cabin Creek, Cabin Creek Medical Center, 
Dawes, 2nd Wednesday, 8-10 A. M. — Sept. 
14, “Emergency Evaluation and Management 
of Acute Dyspnea,” Patricia Treharene, M. D. 
Oct. 12, “Lower Gastrointestinal Bleeding,” 
Warren Point, M. D. 

Cassaway, Braxton Co. Memorial Hospital, 1st 
Wednesday, 7-9 P. M. — Sept. 7, “Pediatric 
Update,” Ellen Szego, M. D., and Susan 
Watkins, BSN. 

Oct. 5, “Physical Therapy,” Louise Christen- 
sen, PRT. 

Nov. 2, “Update on Nuclear Medicine,” Steven 
Artz, M. D. 

Madison, 2nd floor. Lick Creek Social Services 
Bldg., 2nd Tuesday, 7-9 P. M. — Sept. 13, 
“Stress-Related Gastrointestinal Disorders,” 
Warren Point, M. D. 

Oak Hill, Oak Hill High School ( Oyler Exit, N 
19) 4th Tuesday, 7-9 P. M. — Sept. 27, 
“Managing High-Risk Pregnancies,” Luis 
Sanchez-Ramos, M. D. 

Welch, Stevens Clinic Hospital, 3rd Wednesday, 
12 Noon-2 P. M. — Sept. 21, “Non-Diabetic 
Endocrine Emergencies, Richard Kleinmann, 
M. D. 

fVhitesville, Raleigh-Boone Medical Center, 4th 
Wednesday, 11 A. M.-l P. M. — Sept. 28, 
“Stress-Related Illnesses,” Jim Peden, M. D. 

Williamson, Appalachian Power Auditorium, 1st 
Thursday, 6:30-8:30 P. M. — Sept. 1, 
“Therapeutic Drug Monitoring” (speaker to 
be announced ) . 

Oct. 6, “Appropriate Use of Antibiotics,” 
Richard Parker, M. D. 


AMA Appoints WVU Student 

West Virginia University medical student 
David J. Brailer of Morgantown has been ap- 
pointed to the American Medical Association’s 
Council on Long Range Planning and Develop- 
ment. Student representatives to various AMA 
bodies were appointed during the June meeting 
of the Board of Trustees. 


September, 1983, Vol. 79, No. 9 


207 



Hypertension Program Planned 
September 14, Charleston 

“Advances in Hypertension,” a one-day CME 
program of papers, panel discussions, workshops 
and exhibits, will be held on September 14 in 
Charleston. 

The site will be the West Virginia University 
Medical Center Education Building Auditorium. 

The program is designed for physicians, 
pharmacists, nurses, and health care providers 
involved in the care of the hypertensive patient. 

Registration is requested by September 7. 

The morning session 
will begin with a paper 
on “Pathophysiology 
and Complications of 
the Disease States,” by 
Charles Swartz, M. D., 
Professor of Medicine 
and Director, Division 
of Nephrology and 
Hypertension, Hahne- 
mann Medical College, 
Philadelphia. 

Following will be a 
panel on “Workup 
and Management Strat- 
egies of the Hypertensive Patient,” including 
presentations on: “The Mild and Moderate 

Hypertensive Patient,” Mary Lou Lewis, M. D., 
Clinical Professor of Medicine, WVU Charleston 
Division, and Senior Nephrologist, Charleston 
Renal Group; “The Severe and Malignant 
Hyptertensive Patient,” Alan B. Schwartz, M. D.. 
Professor of Medicine, Director of Nephrology 
Service, and Director of Center of Aging, 
Hahnemann Medical College; and “The Rational 
Workup of the Hypertensive Patient,” Derrick 
L. Latos, M. D., The Wheeling Clinic. 

Concurrent Workshops 

Concurrent workshop sessions at 1 P. M. will 
be “Non-Drug Therapy and Psychosocial Impli- 
cations of Hypertension,” Lee A. Hebert, M. D., 
Professor of Medicine and Director, Division of 
Renal Disease, The Ohio State University; 
“Treatment of the Pregnant Hypertensive Pa- 
tient,” Gabriel G. Szego, M. I)., Charleston 
Renal Group and Clinical Assistant Professor of 
Medicine, WVU Charleston Division; and “The 
Role of the Nurse and the Pharmacist in the 
Management of Hypertension,” Jan Chapin, 
R.N., Assistant Director, Primary Care Coordi- 
nator, Statewide Hypertension Program, West 


Virginia Department of Health; and Mary Beth 
Gross. Pharm. D., Assistant Professor of Clinical 
Pharmacy, WVU Charleston Division. 

Concurrent workshop sessions at 2 P. M. will 
he “Nutritional Aspects of Hypertension,” 
Beverly P. Mann, R.D., Clinical Dietitian, 
Charleston Renal Group; “Treatment of Essential 
Hypertension in the Pediatric Patient,” Colette 
Gushurst, M. D., Assistant Professor of Pedi- 
atrics, Marshall University School of Medicine; 
and “Hypertensive Treatment in the Renal 
Patient,” Doctor Swartz. 

Paper, Summary to Close Program 

Closing out the program will be a paper on 
“Advances in Hypertension” by Doctor Schwartz 
and a summary by Frederick C. Whittier, M. D., 
WVU Professor of Medicine and Chief, Nephro- 
logy Section, Morgantown. 

The registration fee for physicians will be $38. 

Sponsors are the Charleston Area Medical 
Center, WVU Charleston Division, Charleston 
Renal Group, West Virginia Department of 
Health, and WVU School of Pharmacy. 

Doctor Lewis is Program Chairman. 

For additional registration and other infor- 
mation, telephone the WVU Charleston Division 
Office of Continuing Education at (304) 347- 
1249. 

A free public session will be held by the 
sponsors on Tuesday evening, September 13, at 
the same site. Doctor Hebert will be the featured 
speaker, and there also will be exhibits, a poster 
session and free blood pressure screening. 


Group Management Meeting 
September 23-25 

The West Virginia Group Management Asso- 
ciation w ill meet September 23-25 at the Charles- 
ton Marriott Hotel. 

Robert C. Bohlmann, Administrator for the 
Arlington (Texas) Medical Association, will be 
the featured speaker on “Group Practice Mar- 
keting/Public Relations” and “Physician Income 
Distribution Alternatives.” 

A representative of the State Medical Associa- 
tion also will be present. 

Other topics to be covered will be “Develop- 
ing Long Range Plans,” “DRG Impact on Physi- 
cians,” and “Healthcare Competition.” 

For more information, contact Chet Marshall 
at 1-800-642-9706. 



Lee A. Hebert, M. D. 


208 


The West Virginia Medical Journal 


Health Care Coverage 
Urged For Jobless 

The State and American Medical Associations 
have renewed their requests to physicians to help 
the jobless with their health problems. They 
have proposed a letter to be utilized by doctors, 
with modifications to fit different office styles, 
for distribution to patients. 

The new effort follows several others, includ- 
ing one by Harry Shannon, M. D., of Parkers- 
burg, the State Medical Association’s 1982-83 
President, in the March issue of The Journal. 

“The generosity of our physicians who are 
sharing the burden of the economic times with 
their patients is praiseworthy and appreciated,” 
Doctor Shannon wrote in his President’s Page 
message. He added: 

“I would urge you to consider, where 
appropriate, extending and enlarging this gener- 
osity, to insure that those who need quality 
medical care are not hampered in their efforts 
to achieve it by the fear of inability to pay.” 

Here is the sample letter now being suggested 
for physicians’ patients, and designed to make 
them aware of doctors’ desires to respond to 
economic hardships faced by the unemployed or 
needy: 

Dear Patient: 

At a time when substantial unemployment, 
along with reductions in Medicaid and disability 
programs, continue to make it difficult for in- 
creasing numbers of people to obtain necessary 
health care, / want to assure my patients that 
such circumstances will not be a barrier to my 
provision of necessary medical services. 

I believe it is important that you continue to 
receive the medical care you need. Provision of 
the best medical care possible is, as always, my 
primary goal in serving my patients. 

If you would have difficulty in paying my bills 
because of unemployment and a loss of health 
insurance or due to a cutback in Medicaid or 
disability program, please let me or my staff 
know. We can make arrangements to provide 
for necessary care on a fee-reduced basis, or 
make other financial arrangements. 

Most important, do not hesitate to seek my 
services because you are having financial prob- 
lems beyond your control. Please let me or my 
office staff know if you would like to discuss my 
policy on this further. 

Sincerely, 

, M.D. 


Doctors Join Staff of WVU’s 
Charleston Division 

Four physicians recently joined the staff of 
the West Virginia University Medical Center/ 
Charleston Division: Yvette Ysaura Longoria, 
Instructor of Surgery; Kathleen Vincent Previll, 
Assistant Professor, Pediatrics; Luis Sanchez- 
Ramos, Assistant Professor, Obstetrics and 
Gynecology; and Beverly Dee Spaulding, Assist- 
ant Professor, Family Practice. 

Doctor Longoria, a native of Elsa, Texas, 
received ber M. D. degree from the University 
of Monterrey, Mexico. She completed an intern- 
ship in surgery at the Regina (Saskatchewan) 
General Hospital in Canada, and a five-year 
surgery residency at Charleston Area Medical 
Center. 

Doctor Previll received A.B. and M.D. degrees 
from West Virginia University. Although a 
native of Wildwood, New Jersey, she attended 
public school in Wellsburg, West Virginia. She 
completed pediatric residencies at the Akron 
(Ohio) Children's Hospital and the Children’s 


Review A Book 


The following books have been received by the 
Headquarters Office of the State Medical Associa- 
tion. Medical readers interested in reviewing any 
of these volumes should address their requests to 
Editor, The West Virginia Medical Journal, Post 
Office Box 1031, Charleston 25324. We shall be 
happy to send the books to you, and you may 
keep them for your personal libraries after sub- 
mitting to The Journal a review for publication. 

General Ophthalmology, 10th Edition, by 
Daniel Vaughan, M. D.; and Taylor Asbury, 
M. D. 407 pages. Price $17. Lange Medical 
Publications, Los Altos, California 94022. 
1983. 

Review of Medical Physiology, 11th Edition, 
by William F. Ganong, M. D. 643 pages. Price 
$20. Lange Medical Publications, Los Altos, 
California 94022. 1983. 

Handbook of Pediatrics, 14th Edition, by 
Henry K. Silver, M. D.; C. Henry Kempe, M. D.; 
and Henry B. Bruyn, M. D. 883 pages. Price 
$13. Lange Medical Publications, Los Altos, 
California 94022. 1983. 

Handbook of Poisoning, 11th Edition, by 
Robert H. Dreisbach, M. D. 632 pages. Price 
$11. Lange Medical Publications, Los Altos, 
California 94022. 1983. 


September, 1983, Vol. 79, No. 9 


209 



memorial Hospital in Oklahoma City. Between 
residencies, she served as a General Medical 
Officer with the U. S. Army at Fort Benning, 

Georgia. 

Oklahoma Fellowships 

At the University of Oklahoma’s Health 
Sciences Center she completed fellowships in 
ambulatory pediatrics. 

After a year of private practice at the Oberlin 
(Ohio) Clinic, she was a rural pediatrician with 
the West Virginia State Health Department. 

Immediately prior to her faculty appointment. 
Doctor Previll was Coordinator of the Pediatric 
Clinic at CAMC’s Memorial Division. 

Doctor Sanchez-Ramos was born in Caracas, 
Venezuela, and attended high school in Miami, 
Florida. Upon graduation from the University 
of Madrid, Spain, he received M.D. degrees from 
Dominican Republic’s Universidad Autonoma 
Santo Domingo and Venezuela’s Universidad del 
Zulia in Maracaibo. 

After an internship at the Baptist Memorial 
Hospital in Jacksonville, Florida, he completed 
a residency in obstetrics and gynecology at the 
Medical College of Georgia, and fellowships in 
genetics and maternal-fetal medicine at the Uni- 
versity of Miami. 

High-Risk Pregnancies 

As a board-eligible specialist in maternal-fetal 
medicine, he will provide care and consultation 
for patients with high-risk pregnancies. 

Doctor Spaulding, a native of San Antonio, 
Texas, received her M. D. degree from Mexico’s 
University of Monterrey, and completed a family 
practice residency at the Family Practice Center, 
Thomas Memorial Hospital. 

In addition to her appointment to the Depart- 
ment of Family Practice, Doctor Spaulding also 
will serve as Assistant Director of the Kanawha 
Valley Family Practice Residency Program. 


Golden Mountaineer Club 
Now Three Years Old 

West Virginia’s Golden Mountaineer Discount 
Program for those age 60 and older now is itself 
three years old. It is administered by the West 
Virginia Commission on Aging, assisted by an 
advisory committee of businessmen and com- 
munity leaders. 

Participation by those in the business com- 
munity of course is voluntary. The Commission 
on Aging has advised that those desiring more 
information should contact Mr. Michael Marlowe, 
Director, Golden Mountaineer Club, Building 1, 
Room B-41, State Capitol, Charleston 25305. 


Hospital Staff Reps Meet 
First Time With AMA 

When the American Medical Association 
House of Delegates met in Chicago in June, the 
351 delegates seated included 281 representing 
state medical associations; 61 representing na- 
tional medical specialty societies, and 9 section 
and service delegates representing hospital medi- 
cal staffs, medical students, medical schools, 
resident physicians, Army, Navy, Air Force, 
USPHS, and the Veterans Administration. The 
House considered 147 resolutions and 74 reports. 

The American Hospital Association and the 
American Dental Association sent official observ- 
ers. At this meeting the House voted to invite 
also the American Osteopathic Association, 
American Group Practice Association and the 
National Medical Association to send official ob- 
servers. 

Nearly 700 representatives of hospital medical 
staffs met for the first time in conjunction with 
the AMA House, and section officers were 
elected, including an AMA delegate. The section 
introduced eight resolutions. With 7,000 U. S. 
hospitals eligible to send representatives, at- 
tendance is expected to grow. The section will 
meet again at the Interim Meeting in Los 
Angeles, and all hospitals are urged to send repre- 
sentatives. The section will meet December 2-4, 
and the AMA House meets December 4-7. 

JACH Manual Changes 

After extensive debate on the Medical Staff 
Section of the JCAH Accreditation Manual for 
Hospitals, the House affirmed the following prin- 
ciples as the basis for any revisions in the JCAH 
Manual: 

— Continue the use of the term “medical staff” 
in the title of the chapter and throughout 
the manual. 

- — Delete any specific references to limited 
licensed practitioners now contained in the 
medical staff chapter of the 1983 Accredita- 
tion Manual for Hospitals. This does not 
preclude such practitioners from having 
hospital privileges consonant with their 
training, experience, and current compe- 
tence if approved by the normal creden- 
tializing process. 

— Provide consideration of qualified limited 
licensed practitioners in accordance with 
state law and when approved by the execu- 
tive committee of the medical staff and by 
the governing board and, when their ser- 
vices are appropriate to the goals and mis- 


210 


The West Virginia Medical Journal 


sions of that hospital, taking into account 
the training, experience, and current clinical 
competence of the practitioners. 

— Provide that the executive committee of the 
medical staff be composed of members se- 
lected by the medical staff, or appointed in 
accordance with the hospital bylaws. All 
members of the active medical staff, as de- 
fined in the medical staff bylaws, are eligible 
for membership on the executive committee, 
and a majority of the executive committee 
members must be fully licensed physician 
members ( doctors of medicine or doctors of 
osteopathy) of the active medical staff in 
the hospital. 

— Assure that the medical care of all patients 
remains under the supervision and direction 
of qualified, fully licensed physicians (doc- 
tors of medicine or doctors of osteopathy). 

— Assure that the continued high quality of 
care, credentializing of physicians and other 
licensed practitioners, and effective quality 
assurance programs remain under the super- 
vision and direction of fully licensed physi- 
cians. 

Indemnity Versus UCR 

Another issue that generated lengthy discus- 
sion was a report presenting an analysis of pay- 
ment mechanisms utilized by third-party payors 
for reimbursement of physicians’ services. 

The Council on Medical Service presented a 
comprehensive discussion of indemnity versus 
UCR reimbursement, and asked the delegates to 
consider the matter and discuss it with their con- 
stituents over the next six months in preparation 
for discussion and possible action at the 1983 
interim meeting in Los Angeles. 

Under an indemnity system, a third party pays 
a physician a set amount for a covered service, 
with the physician free to charge his own fee and 
collect any charge in excess of the level at which 
the third party decides to pay. 

The Council believes that if third parties 
change to an indemnity system of payment, pa- 
tients would be benefitted by: 

— Insuring their continued access to care not 
through external regulation of fees but 
through market forces. 

— Increasing both physicians’ and patients’ 
sensitivity to costs and quality of care pro- 
vided. 

— Allowing them continued freedom of choice 
rather than being increasingly restricted to 
“participating” providers as a condition of 
coverage. 


— Facilitating understanding and comparison 
of insurance coverages. 

The report said that rate determination for 
third parties would be simpler. For physicians, 
the Council believes that the indemnity approach 
could bring improved patient /physician inter- 
action by eliminating false expectations of the 
amount of the third-party payment. This 
approach, the report added, also will provide 
physicians the freedom to charge what they 
believe to be a fair and equitable fee, subject 
only to normal and effective market constraints. 


88 Members In New WVU 
Class Announced 

Sixty-three men and 25 women entered their 
first year in the West Virginia University School 
of Medicine when classes began August 22. 

The new class, which includes 84 West Vir- 
ginians, three Pennsylvanians and one New 
Yorker, completed undergraduate work at 39 
different colleges or universities. More than half, 
or 53, received their premedical education in 
West Virginia, with WVU accounting for 36. 

Five attended Wheeling College, and three are 
graduates of West Virginia Wesleyan. Marshall 
University has two graduates as do Shepherd and 
Alderson-Broaddus colleges. Bethany College, 
West Virginia Institute of Technology and Con- 
cord College are represented by one graduate 
each. 

The remaining 35 attended 30 different out-of- 
state colleges or universities. 

The West Virginians come from 23 counties. 
Thirty-two class members list home addresses 
in Monongalia County. This reflects in some 
cases the change of legal address made by stu- 
dents during their undergraduate days at WVU. 

Ten members of the class list home addresses 
in Ohio County. Eight are from Kanawha Coun- 
ty and six are from Cabell. 

Applications were mailed to 247 West Vir- 
ginians and 189 non-residents. Interviews were 
granted to 239 state and 53 out-of-state appli- 
cants. 

Grade point average for the applicants ac- 
cepted as of April 27 was 3.44 with a science 
average of 3.57. 

Names listed represent those accepted into the 
class as of July 1, with the exception of one 
class member who requested that his name not be 
released for publication. The listing does not 


September, 1983, Vol. 79, No. 9 


211 


include the names of alternates who may be ad- 
mitted if withdrawals occur. 

Members of the class include: 

Berkeley : Hedgesville — Allen M. Lewis; 

Brooke: Weirton — Robert Starr; Cabell: Hun- 
tington — Allen B. Joseph, Susanne E. Fix, Glenn 

C. Robinson, Mariel M. Smith, and David M. 
Vaziri; Milton — Michael J. Sullivan; Fayette: 
Fayetteville — John L. Stanley; Hancock: Weir- 
ton — Robert D’Angelo, Stephen Holbrook, Gina 
M. Rasicci, and Ronald S. Wargacki; 

Hardy: Mathias — Crystl L. Dove; Harrison: 
Bridgeport — Toni B. Goody koontz; Jefferson: 
Charles Town — Thomas S. Wilson; Shepherds- 
town — Charles B. Hicock; Kanawha: Charles- 

ton — William P. Cheshire, Jr., Lisa A. Copen- 
haver, John P. Hayes, Robert B. Jackson, Beth 

D. Kagen, Carol A. Proops, and John J. Schaefer; 
Pinch — Dayton D. Payne; 

Marion: Fairmont — Bruce E. Mazurek and 

Gregory A. Thompson; Mason: Point Pleasant 
— Elizabeth R. Boonsue; Mercer: Bluefield — 
Daniel L. Sadler; Flat Top — Glen A. Marino; 
Mingo: Delbarton — John L. Goad; 

Monongalia: Morgantown — Andrew K. 

Bean, Kathleen H. Blackburn, James F. Cahill, 
Felicia K. Cain, Jyotsna N. Dalai, Bruce J. 
Davidson, Richard J. DeAngelis, Jaimela J. 
Dulaney, Mark S. Franczak, William C. Hamil- 
ton, Katherine Hwu, Evan A. Jones, Bruce P. 
Klein, Jay J. Libys, Matthew L. Miller, Jack C. 
Moore, John P. Muse, Susan E. Palmer, David 
J. Rodak, Judith T. Romano, James H. Sherry, 
Donald R. Shoenthal, Jr., Timothy K. Simmons, 
Edward E. Stewart, Jr., Michael Thomas, Mark 
0. Thornton, Devin J. Troyer, George J. LUlrich, 
Anthony J. Viti, Russell I. Voltin, Bruce D. 
Weinstein, and Wynne E. Woodyear; 

Morgan: Berkeley Springs — Douglas H. 

Howerton; Ohio: Wheeling — Deniz F. Bastug, 
Kathleen P. Bors, John P. Dagirmanjian, Ed- 
ward D. DeVelin, Helen M. Kellett, William H. 
McCuskey, James E. McDermott III, Nicholas D. 
Poulos, Randall A. Swain, and Todd A. Wits- 
berger; Preston: Kingwood — Daniel B. Thistle- 
thwaite; Terra Alta — Susan M. Sypolt; 

Putnam: Hurricane — Sabrina D. Craigo; 

Raleigh: Daniels — Mark Warvariv; Ritchie: 
Harrisville — Debra S. Hinzman; Summers: Elton 
— Deborah Schmidt; Hinton — Lisa S. Persinger; 
Wood: Parkersburg — Michael A. Russell; 

Vienna- — Mark T. Darnell; 

Out-of-State: New York, Flushing — Marilyn 
Radke; Pennsylvania, Allison Park — John T. 
Cinicola; Brownsville — John J. Duda, Jr.; Pitts- 
burgh — Gary R. Bergman. 


Surgery, Educational Skills 
Programs Set By MU 

Countinuing medical education programs on 
surgery and educational skills are among those 
currently being announced by Marshall Uni- 
versity School of Medicine. 

William A. Altemeier, M. D., a national 
authority on surgical infections, leads the list 
of guest faculty for Marshall’s fourth annual 
Surgical Symposium on September 24 in Me- 
morial Student Center. 

The program will include talks on Staph, 
aureus infections, gram negative infections, 
peritonitis, and intra-abdominal abscess, accord- 
ing to Charles W. Jones, Ph.D., CME Director. 
Other topics include “Tissue Gas, Death, Life” 
and “Infection Complications in the Impaired 
Host. Workshops on hepatitis, genito-urinary 
infections and antibiotic use also will be offered. 

In addition to Doctor Altemeier, who is the 
Christian R. Holmes Professor Emeritus of 
Surgery at the University of Cincinnati, the guest 
faculty includes Donald E. Fry, M. D., Chief of 
Surgery at the Cleveland Veterans Administra- 
tion Hospital; Westley Furste, M. D., Clinical 
Professor of Surgery at Ohio State University 
and Chairman of Surgery at Mt. Carmel Medical 
Center, and Robert L. Yarrish, M. D., Assistant 
Professor of Medicine in the Division of Infec- 
tious Diseases at the University of Kentucky 
Medical Center. 

Six MU physicians also will serve on the 
symposium’s faculty. 

CME Credit, Fees 

The program has been approved for continu- 
ing medical education credit by the American 
Medical Association, the American Academy of 
Family Physicians, and MU. 

The fee is $65 for physicians and $10 for 
resident physicians and medical students. 

The School of Medicine will offer its volunteer 
and full-time faculty a special program on edu- 
cational skills October 20-22, according to Dr. 
David K. Heydinger, Associate Dean for 
Academic Affairs. About 250 community physi- 
cians serve on MU’s volunteer faculty. 

The conference will address topics such as 
effective audiovisual use, lecturing, and teach- 
ing one-on-one in the classroom, in the office 
and on hospital rounds. It also will include ses- 
sions on preparing for the preceptorship ex- 
perience, reducing stress in the office and evalu- 
ating students. 

(continued on next page) 


212 


The West Virginia Medical Journal 


Guest Faculty 

Guest faculty for the event will include Glen 
Geelhoed, M. D., Associate Professor of Surgery 
at George Washington University Medical 
Center; James Young, Ph.D., Vice Chancellor 
for Health Affairs, West Virginia Board of 
Regents; John-Henry Pfifferling, Ph.D., Director 
of the Center for the Well-Being of Health Pro- 
fessionals, and Xenia Tonesk, Ph.D., Director 
of the Clinical Evaluation Project, Association 
of American Medical Colleges. 

For more information on either conference, 
contact Doctor Jones at (304) 52-0515. 


Cleveland Clinic Physician 
Addresses Urologists 

Dr. Ralph A. Straffon, Chairman of the De- 
partment of Urology at the Cleveland Clinic, 
was a principal speaker for the recent spring 
meeting of the West Virginia Urological Society 
at the Greenbrier in White Sulphur Springs. 

This was reported by Dr. Tara C. Sharma of 
Huntington, the Society’s Treasurer, who com- 
mented, “We encourage all of the urologists in 
the state to attend in greater numbers and not 
miss out on the good lectures and mutual dis- 
cussions on problems peculiar to our region.” 

Doctor Straffon gave lectures on adrenal 
surgery, adrenal physiology, and disease of the 
adrenal. Doctor Sharma said. He added that 
there were other papers on the evaluation and 
treatment of renal and adrenal masses, and an 
x-ray session in the afternoon of the one-day 
meeting. 

The meeting was held in conjunction with that 
of the West Virginia Chapter, American College 
of Surgeons. 


Gastroenterology CME Program 
To Include Duke Doctors 

Two faculty members from the Duke Uni- 
versity School of Medicine will speak during an 
afternoon program, “Gastroenterology Up-date,” 
on October 5 in Charleston. 

The two Duke physicians will be Drs. John T. 
Garbutt, Jr., Associate Professor of Medicine, 
Gastroenterology Division, who will talk on 
peptic ulcer disease, and Paul Killenberg, As- 
sociate Professor of Medicine and Chief, Liver 
Service, who will discuss chronic hepatitis. 

The CME offering, sponsored by Charleston 
Area Medical Center and West Virginia Uni- 


versity Medical Center, Charleston Division, will 
begin at 1 P. M. following registration starting 
at noon. The site will be the WVU Medical 
Center Education Building Auditorium. 

Also on the program will be talks by Drs. 
Brittain Mcjunkin, Clinical Assistant Professor 
of Medicine, WVU Charleston Division, on 
esophageal motor disorders; and Duane D. 
Webb, Associate Professor of Medicine, Marshall 
University School of Medicine, on colonic polyps. 

William 0. McMillan, Jr., Charleston gastro- 
enterologist, will be the moderator. 

Adjournment will be at 5 P. M. 


State Financial Woes Hit 
Medical Services Area 

State Government’s financial woes apparently 
mean new problems for the Medicaid Program, 
and at least some inconvenience for physicians 
and others providing services to recipients. 

The Department of Human Services, which 
administers the medical services program and 
funds, has explained that the agency is receiving 
only one-twelfth of its state appropriation on a 
monthly basis. 

This makes it difficult to pick up carry-over 
bills the agency has from the past fiscal year and 
meet current liabilities. In fact, an agency 
spokesman has estimated that the catch-up 
process will continue through September. 

The money problem, and the monthly allot- 
ment pattern, have as a background a recent 
order by Governor Rockefeller directing a new 
three-per cent spending cut for state agencies 
for the current fiscal year. 


Vascular Surgery Conference 
Planned For Snowshoe 

Physicians from Vanderbilt University, Ohio 
State University and the University of Pitts- 
burgh will be included on the faculty for the 
Second Annual Snowhoe Vascular Surgery Con- 
ference to be held next February 19-22. 

The program, which will deal with current 
topics in vascular surgery, will be held at the 
Snowshoe ski resort under the sponsorship of the 
Office of Continuing Medical Education, West 
Virginia University School of Medicine, Mor- 
gantown, and the WVU Department of Surgery. 

Registration information can be obtained from 
the CME office at 104 Basic Science Building, 
WVU Medical Center, P. 0. Box 6302, Morgan- 
town 26506-6302. Telephone (304) 293-3937. 


September, 1983, Vol. 79, No. 9 


213 


Public Entitled To Amounts 
Medicaid Pays Doctors 

Kanawha County Circuit Judge John Hey has 
ruled, in a case brought by the West Virginia 
State Medical Association, that amounts paid 
physicians under the state’s Medicaid Program 
are public information and may be released to 
the press and others. 

The Medical Association, in the first case of 
its kind related to West Virginia’s 1977 Freedom 
of Information Act, brought an injunctive and 
declaratory judgment action against Human 
Services Commissioner Leon Ginsberg to pre- 
vent public release of such personalized infor- 
mation. 

Because of some questions it saw in the public 
interest and privacy area, the Association’s effort 
was primarily directed toward obtaining a 
judicial determination of the scope of the 1977 
act, and what information could be considered 
releasable. 

Judge Hey observed that whether a physician 
participates in the Medicaid Program is a mat- 
ter of personal decision, and held that amounts 
paid are public information. 

Pending a hearing on August 15, Judge Hey 
granted a temporary injunction August 3. After 
his ruling, also on August 15, he continued the 
injunction in effect for 10 days to permit a 
decision by the Association as to whether it 
might desire to appeal to the West Virginia 
Supreme Court of Appeals. 

There was no appeal. 


Prescription Drug Abuse 
Attack Launched 

Prescription drug abuse recently came under 
attack as the Florida Medical Association, 
Massachusetts Medical Society and Michigan 
Medical Society endorsed field tests of the 
American Medical Association model for identi- 
fying “script doctors.” Several other medical 
societies are gearing up to help pinpoint the 
sources of drug diversion in their states. Partici- 
pating medical societies will work with existing 
state and federal drug enforcement agencies as 
well as educate physician members about the 
ruses that addicts and others employ to obtain 
drugs. 

Current federal data show that prescribable 
drugs are involved in almost 60 per cent of all 
drug-related emergency room visits and 70 per 
cent of all drug-related deaths. 


Medical Meetings 


Sept. 7-10 — Peripheral Vascular Disease Symposium 
(Saint Anthony Hospital), Columbus, OH. 

Sept. 23-25 — W. Va. Group Management Assoc., 
Charleston. 

Sept. 24 — MU Surgical Symposium, Huntington. 

Sept. 29-Oct. 1 — Am. Assoc, for the Surgery of 
Trauma. 

Sept. 29-Oct. 2 — Am. Society of Internal Medicine, 
San Francisco. 

Sept. 30-Oct. 1 — W. Va. Chapter, Am. College of 
Surgeons, Morgantown. 

Oct. 2-5 — Am. Neurological Assoc., New Orleans. 

Oct. 5-8 — Am. Thyroid Assoc., New Orleans. 

Oct. 7-8 — AMA Congress on Occupational Health, 
Beachwood, OH. 

Oct. 16-21 — Am. College of Surgeons, Atlanta. 

Oot. 20-22 — Educational Skills (MU Medical 
School), Huntington. 

Oct. 22-27 — Am. Academy of Pediatrics, San Fran- 
cisco. 

Oct. 23-26 — Am. College of Gastroenterology, Los 
Angeles. 

Oct. 23-27 — Am. College of Chest Physicians, 
Chicago. 

Oct. 24-27 — Am. College of Emergency Physicians, 
Atlanta. 

Oct. 26-30 — Am. Academy of Child Psychiatry, San 
Francisco. 

Oct. 30-Nov. 3 — Am. Academy of Ophthalmology, 
Chicago. 

Nov. 6-9 — Scientific Assembly, Southern Medical 
Assoc., Baltimore. 

Nov. 7-9 — Am. Medical Women’s Assoc., Dearborn, 
MI. 

Dec. 4-7 — Interim Meeting, AMA House, Los 
Angeles. 

1984 

Jan. 27-29 — 17th Mid-Winter Clinical Conference, 
Charleston. 

Feb. 9-14 — Am. Academy of Orthopaedic Surgeons, 
Atlanta. 

Feb. 12-15 — W. Va. Perinatal Assoc., Snowshoe. 

March 17 — Annual Meeting, W. Va. Affiliate, 
American Diabetes Assoc., Wheeling. 

May 2-5 — W. Va. Chapter, Am. College of Surgeons; 
and W. Va. Otolaryngological Society, White 
Sulphur Springs. 


214 


The West Virginia Medical Journal 



WHY BMW CHOSE 
TO CHANGE THE 

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ROUTE 60, WEST ST. ALBANS 722-4900 


WVU Medical Center 
-News— 


Compiled from material furnished by the Medical Center 
News Service, Morgantown, W. Va. 


More State Heart Surgery 
Said Available 

Heart surgery is entering a new era, and 
WVU Medical Center has expanded its program 
to meet the resulting challenges. 

In recent years coronary artery bypass has 
become one of the most common major o